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Daungsupawong H, Wiwanitkit V. Comment on "Evaluation of valganciclovir's neutropenia risk in pediatric solid organ transplant recipients utilizing two dosing regimens". Pediatr Transplant 2024; 28:e14754. [PMID: 38623879 DOI: 10.1111/petr.14754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/27/2024] [Indexed: 04/17/2024]
Affiliation(s)
| | - Viroj Wiwanitkit
- Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Chennai, India
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2
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O'Sullivan KF, Patell R, Freed J. CRE24-042: Microgranular Acute Promyelocytic Leukemia Presenting as Recurrent Stroke and Isolated Neutropenia. J Natl Compr Canc Netw 2024; 22:CRE24-042. [PMID: 38579833 DOI: 10.6004/jnccn.2023.7321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
| | | | - Jason Freed
- 1Beth Israel Deaconess Medical Center, Boston, MA
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3
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Fioredda F, Beccaria A, Casartelli P, Turrini E, Contratto C, Giarratana MC, Bagnasco F, Saettini F, Pillon M, Marzollo A, Zanardi S, Civino A, Onofrillo D, Lanciotti M, Ceccherini I, Grossi A, Coviello D, Terranova P, Lupia M, Del Borrello G, Uva P, Cangelosi D, Cavalca G, Miano M, Dufour C. Late-onset and long-lasting neutropenias in the young: A new entity anticipating immune-dysregulation disorders. Am J Hematol 2024; 99:534-542. [PMID: 38282561 DOI: 10.1002/ajh.27221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/09/2023] [Accepted: 01/01/2024] [Indexed: 01/30/2024]
Abstract
This study identifies a new chronic form of immune neutropenia in the young with or without detectable indirect anti-neutrophil antibodies, characterized by mild/moderate neutropenia low risk of severe infection (14%), tendency to develop autoimmune phenomena over the course of the disease (cumulative incidence of 58.6% after 20 years of disease duration), leukopenia, progressive reduction of absolute lymphocyte count and a T- and B-cell profile similar to autoimmune disorders like Sjogren syndrome, rheumatoid arthritis, and systemic lupus erythematosus (increased HLADR+ and CD3 + TCRγδ cells, reduced T regulatory cells, increased double-negative B and a tendency to reduced B memory cells). In a minority of patients, P/LP variants related to primary immuno-regulatory disorders were found. This new form may fit the group of "Likely acquired neutropenia," a provisional category included in the recent International Guidelines on Diagnosis and Management of Neutropenia of EHA and EUNET INNOCHRON ACTION 18233. The early recognition of this form of neutropenia would help clinicians to delineate better specific monitoring plans, genetic counseling, and potentially targeted therapies.
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Affiliation(s)
- F Fioredda
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - A Beccaria
- Epidemiology and Biostatistics Unit and DOPO Clinic-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - P Casartelli
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - E Turrini
- Unit of Pediatric and OncoHematology, Department of Mother and Child, Azienda Ospedaliera Universitaria, Parma, Italy
| | - C Contratto
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - M C Giarratana
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - F Bagnasco
- Biostatistics Unit, Scientific Directorate, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - F Saettini
- Department of Pediatric Onco-Hematology, San Gerardo Hospital, Fondazione MBBM, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - M Pillon
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, AziendaOspedaliera-University of Padova, Padua, Italy
| | - A Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, AziendaOspedaliera-University of Padova, Padua, Italy
| | - S Zanardi
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - A Civino
- Unit of Rheumathology and Immunology-ospedale Vito Fazzi, Lecce, Italy
| | - D Onofrillo
- Pediatric Hematology and Oncology Unit, Department of Hematology, Spirito Santo Hospital, Pescara, Italy
| | - M Lanciotti
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - I Ceccherini
- Laboratory of Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - A Grossi
- Laboratory of Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - D Coviello
- Laboratory of Human Genetics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - P Terranova
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - M Lupia
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - G Del Borrello
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
- Pediatric OncoHematology, Pediatrics Department, Hospital Città Della Salute e Della Scienza, University of Turin, Turin, Italy
| | - P Uva
- Clinical Bioinformatics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - D Cangelosi
- Clinical Bioinformatics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - G Cavalca
- Clinical Bioinformatics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
- University of Bologna, Bologna, Italy
| | - M Miano
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - C Dufour
- Haematology Unit-IRCCS Istituto Giannina Gaslini, Genova, Italy
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Arnhold APC, Araújo HGS, Cruz AF, Toffolo MCF, Mauricio SF. Use of neutropenic diet in the nutritional care of pediatric cancer patients with neutropenia: a scoping review. J Pediatr (Rio J) 2024; 100:132-142. [PMID: 37813344 PMCID: PMC10943308 DOI: 10.1016/j.jped.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE to carry out a scoping review with the purpose of mapping the scientific evidence on the use of the neutropenic diet in neutropenic pediatric cancer patients. SOURCE OF DATA The scoping review protocol was prepared in accordance with the PRISMA-ScR and the checklist before the literature search was performed. Articles on nutritional management in adults or on the treatment of other diseases, and articles that were not in Portuguese or English and published before the year 2000, were excluded. Data were extracted based on the Cochrane Consumer and Communication Review Group form. SUMMARY OF THE FINDINGS Three hundred and forty scientific articles were identified, with the final sample of this review consisting of nine studies. Although the neutropenic diet has been part of the nutritional management of pediatric cancer patients for more than 20 years, there is still great variation in the criteria for indicating use and starting and discontinuing it, as well as in the nutritional composition of the diet. Furthermore, there is no consensus on the impact of using a neutropenic diet on different clinical and nutritional outcomes. CONCLUSION In the absence of guidelines that standardize the use of a neutropenic diet in pediatric patients with neutropenia, there are heterogeneous approaches reported in the literature, even within the same institution. The available literature presents an absence of evidence on the use, viability, and effectiveness of the neutropenic diet in oncological children with neutropenia. More studies are needed to identify the real impact of the neutropenic diet on clinical and nutritional outcomes.
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Affiliation(s)
| | | | - Ana Facury Cruz
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Belo Horizonte, MG, Brazil
| | | | - Silvia Fernandes Mauricio
- Universidade Federal de Ouro Preto, Departamento de Nutrição Clínica e Social, Ouro Preto, MG, Brazil.
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Grünert SC, Derks TGJ, Mundy H, Dalton RN, Donadieu J, Hofbauer P, Jones N, Uçar SK, LaFreniere J, Contreras EL, Pendyal S, Rossi A, Schneider B, Spiegel R, Stepien KM, Wesol-Kucharska D, Veiga-da-Cunha M, Wortmann SB. Treatment recommendations for glycogen storage disease type IB- associated neutropenia and neutrophil dysfunction with empagliflozin: Consensus from an international workshop. Mol Genet Metab 2024; 141:108144. [PMID: 38277989 DOI: 10.1016/j.ymgme.2024.108144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/08/2023] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Glycogen storage disease type Ib (GSD Ib, biallelic variants in SLC37A4) is a rare disorder of glycogen metabolism complicated by neutropenia/neutrophil dysfunction. Since 2019, the SGLT2-inhibitor empagliflozin has provided a mechanism-based treatment option for the symptoms caused by neutropenia/neutrophil dysfunction (e.g. mucosal lesions, inflammatory bowel disease). Because of the rarity of GSD Ib, the published evidence on safety and efficacy of empagliflozin is still limited and does not allow to develop evidence-based guidelines. Here, an international group of experts provides 14 best practice consensus treatment recommendations based on expert practice and review of the published evidence. We recommend to start empagliflozin in all GSD Ib individuals with clinical or laboratory signs related to neutropenia/neutrophil dysfunction with a dose of 0.3-0.4 mg/kg/d given as a single dose in the morning. Treatment can be started in an outpatient setting. The dose should be adapted to the weight and in case of inadequate clinical treatment response or side effects. We strongly recommend to pause empagliflozin immediately in case of threatening dehydration and before planned longer surgeries. Discontinuation of G-CSF therapy should be attempted in all individuals. If available, 1,5-AG should be monitored. Individuals who have previously not tolerated starches should be encouraged to make a new attempt to introduce starch in their diet after initiation of empagliflozin treatment. We advise to monitor certain safety and efficacy parameters and recommend continuous, alternatively frequent glucose measurements during the introduction of empagliflozin. We provide specific recommendations for special circumstances like pregnancy and liver transplantation.
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Affiliation(s)
- Sarah C Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre- University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Helen Mundy
- Evelina London Children's Hospital, London, UK
| | | | - Jean Donadieu
- Centre de reference des neutropénies chroniques, Paris Sorbonne Université, Assistance Publique des Hopitaux de Paris, Hopital Trousseau, Paris 75012, France
| | - Peter Hofbauer
- Department of Production, Landesapotheke Salzburg, Hospital Pharmacy, Salzburg, Austria
| | - Neil Jones
- University Children's Hospital Salzburg, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
| | - Sema Kalkan Uçar
- Division of Metabolism and Nutrition, Department of Pediatrics, Ege University Children's Hospital, Izmir, Turkey
| | | | | | | | - Alessandro Rossi
- Department of Translational Medicine, Section of Paediatrics, University of Naples "Federico II", Naples, Italy
| | | | - Ronen Spiegel
- Pediatric Department B, Emek Medical Center, Afula, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Karolina M Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Organisation, Northern Care Alliance NHS Foundation Trust, M6 8HD Salford, Greater Manchester, United Kingdom
| | - Dorota Wesol-Kucharska
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Warsaw, Poland
| | - Maria Veiga-da-Cunha
- Groupe de Recherches Metaboliques, de Duve Institute, UCLouvain (Université Catholique de Louvain), B-1200 Brussels, Belgium
| | - Saskia B Wortmann
- University Children's Hospital Salzburg, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria; Amalia Children's Hospital, Nijmegen, the Netherlands.
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Manougian HH, Mehta B, Beekman MK, Murphy PM, McDermott DH. Neutropenia, Recurrent Infections, and Warts in a 6-year-old Boy. Pediatr Rev 2024; 45:162-165. [PMID: 38425164 DOI: 10.1542/pir.2021-005348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Haig H Manougian
- Department of Pediatrics, University of Illinois College of Medicine Peoria, OSF Children's Hospital of Illinois, Peoria, IL
| | - Brinda Mehta
- Department of Pediatrics, University of Illinois College of Medicine Peoria, OSF Children's Hospital of Illinois, Peoria, IL
| | - Michele K Beekman
- Department of Pediatrics, University of Illinois College of Medicine Peoria, OSF Children's Hospital of Illinois, Peoria, IL
| | - Philip M Murphy
- Laboratory of Molecular Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - David H McDermott
- Laboratory of Molecular Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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Patel A, Le K, Panek N. Evaluation of valganciclovir's neutropenia risk in pediatric solid organ transplant recipients utilizing two dosing regimens. Pediatr Transplant 2024; 28:e14714. [PMID: 38420722 DOI: 10.1111/petr.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/09/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Valganciclovir is approved for cytomegalovirus prophylaxis in pediatrics using the Pescovitz algorithm. There are reports of valganciclovir overdoses in children with low body surface area and overestimated creatinine clearance utilizing this algorithm. This study compared the incidence of neutropenia and cytomegalovirus infection between the Pescovitz and weight-based dosing algorithms. METHODS A single-center retrospective chart review from January 2010 to September 2018 was performed on pediatric heart, liver, and kidney transplant recipients, who received valganciclovir. Data were collected from the initiation of valganciclovir prophylaxis to 30 days after discontinuation. The primary objective was the incidence of neutropenia in patients receiving valganciclovir dosed by the Pescovitz versus weight-based dosing algorithms. RESULTS This study included 187 pediatric transplant recipients who received valganciclovir dosed via the Pescovitz (62 recipients) or weight-based dosing algorithms (125 recipients). The incidence of neutropenia was higher in the Pescovitz (69.4%) compared to the weight-based dosing group (53.6%; p = .04) including moderate and severe neutropenia. Cytomegalovirus viremia was not significantly different between the two groups and occurred in 4.8% of the Pescovitz group compared to 2.4% of the weight-based group (p = .4). CONCLUSIONS The incidence of neutropenia was greater in recipients receiving valganciclovir dosed via the Pescovitz algorithm compared to the weight-based dosing. There were no significant differences in regard to cytomegalovirus viremia or disease between the two groups.
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Affiliation(s)
- Avani Patel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin Le
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Natalia Panek
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Abramson JS, Palomba ML, Gordon LI, Lunning M, Wang M, Arnason J, Purev E, Maloney DG, Andreadis C, Sehgal A, Solomon SR, Ghosh N, Dehner C, Kim Y, Ogasawara K, Kostic A, Siddiqi T. Two-year follow-up of lisocabtagene maraleucel in relapsed or refractory large B-cell lymphoma in TRANSCEND NHL 001. Blood 2024; 143:404-416. [PMID: 37890149 DOI: 10.1182/blood.2023020854] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
ABSTRACT Lisocabtagene maraleucel (liso-cel) demonstrated significant efficacy with a manageable safety profile as third-line or later treatment for patients with relapsed or refractory (R/R) large B-cell lymphoma (LBCL) in the TRANSCEND NHL 001 study. Primary end points were adverse events (AEs), dose-limiting toxicities, and objective response rate (ORR) per independent review committee. Key secondary end points were complete response (CR) rate, duration of response (DOR), progression-free survival (PFS), and overall survival (OS). After 2-year follow-up, patients could enroll in a separate study assessing long-term (≤15 years) safety and OS. Liso-cel-treated patients (N = 270) had a median age of 63 years (range, 18-86 years) and a median of 3 prior lines (range, 1-8) of systemic therapy, and 181 of them (67%) had chemotherapy-refractory LBCL. Median follow-up was 19.9 months. In efficacy-evaluable patients (N = 257), the ORR was 73% and CR rate was 53%. The median (95% confidence interval) DOR, PFS, and OS were 23.1 (8.6 to not reached), 6.8 (3.3-12.7), and 27.3 months (16.2-45.6), respectively. Estimated 2-year DOR, PFS, and OS rates were 49.5%, 40.6%, and 50.5%, respectively. In the 90-day treatment-emergent period (N = 270), grade 3 to 4 cytokine release syndrome and neurological events occurred in 2% and 10% of patients, respectively. The most common grade ≥3 AEs in treatment-emergent and posttreatment-emergent periods, respectively, were neutropenia (60% and 7%) and anemia (37% and 6%). Liso-cel demonstrated durable remissions and a manageable safety profile with no new safety signals during the 2-year follow-up in patients with R/R LBCL. These trials were registered at www.ClinicalTrials.gov as #NCT02631044 and #NCT03435796.
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Affiliation(s)
- Jeremy S Abramson
- Lymphoma Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - M Lia Palomba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leo I Gordon
- Department of Hematology/Oncology, Northwestern University, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Matthew Lunning
- Hematology/Oncology Division, University of Nebraska Medical Center, Omaha, NE
| | - Michael Wang
- Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jon Arnason
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - David G Maloney
- Clinical Research Division Medicine and Oncology, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Alison Sehgal
- University of Pittsburgh Medical Center: Hillman Cancer Center, Pittsburgh, PA
| | - Scott R Solomon
- Transplant and Cellular Immunotherapy Program, Northside Hospital Cancer Institute, Atlanta, GA
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | | | | | | | | | - Tanya Siddiqi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Weinberg BA, Wang H, Noel MS, He AR, Marshall JL, Weiner LM, Fishbein TM, Hodgins NE, Winslow ER, Jackson PG, Guerra JF, Aguila F, Unger KR. Phase 1 Study of Hypofractionated Proton Beam Radiation Therapy in Adjuvant Pancreatic Cancer (PROTON-PANC). Int J Radiat Oncol Biol Phys 2024; 118:362-367. [PMID: 37717786 DOI: 10.1016/j.ijrobp.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/01/2023] [Accepted: 09/09/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE Despite improvement in systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) frequently experience local recurrence. We sought to determine the safety of hypofractionated proton beam radiation therapy (PBT) during adjuvant chemotherapy. METHODS AND MATERIALS Nine patients were enrolled in a single-institution phase 1 trial (NCT03885284) between 2019 and 2022. Patients had PDAC of the pancreatic head and underwent R0 or R1 resection and adjuvant modified FOLFIRINOX (mFFX) chemotherapy. The primary endpoint was to determine the dosing schedule of adjuvant PBT (5 Gy × 5 fractions) using limited treatment volumes given between cycles 6 and 7 of mFFX. Patients received PBT on days 15 to 19 in a 28-day cycle before starting cycle 7 (dose level 1, DL1) or on days 8 to 12 in a 21-day cycle before starting cycle 7 (DL2). RESULTS The median patient age was 66 years (range, 52-78), and the follow-up time from mFFX initiation was 12.5 months (range, 6.2-37.4 months). No patients received preoperative therapy. Four had R1 resections and 5 had node-positive disease. Three patients were enrolled on DL1 and 6 patients on DL2. One dose-limiting toxicity (DLT) occurred at DL2 (prolonged grade 3 neutropenia resulting in discontinuation of mFFX after cycle 7). No other DLTs were observed. Four patients completed 12 cycles of mFFX (range, 7-12; median, 11). No patients have had local recurrence. Five of 9 patients had recurrence: 3 in the liver, 1 in the peritoneum, and 1 in the bone. Six patients are still alive, 4 of whom are recurrence-free. The median time to recurrence was 12 months (95% CI, 4 to not reached [NR]), and median overall survival was NR (95% CI, 6 to NR; 2-year survival rate, 57%). CONCLUSIONS PBT integrated within adjuvant mFFX was well tolerated, and no local recurrence was observed. These findings warrant further exploration in a phase 2 trial.
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Affiliation(s)
- Benjamin A Weinberg
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC.
| | - Hongkun Wang
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC
| | - Marcus S Noel
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Aiwu R He
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - John L Marshall
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Louis M Weiner
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Thomas M Fishbein
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC
| | | | - Emily R Winslow
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC
| | - Patrick G Jackson
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC
| | - Juan F Guerra
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC
| | - Francisco Aguila
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Keith R Unger
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Abrisqueta P, González-Barca E, Panizo C, Pérez JMA, Miall F, Bastos-Oreiro M, Triguero A, Banerjee L, McMillan A, Seymour E, Hirata J, de Guzman J, Sharma S, Jin HY, Musick L, Diefenbach C. Polatuzumab vedotin plus rituximab and lenalidomide in patients with relapsed or refractory diffuse large B-cell lymphoma: a cohort of a multicentre, single-arm, phase 1b/2 study. Lancet Haematol 2024; 11:e136-e146. [PMID: 38190832 DOI: 10.1016/s2352-3026(23)00345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Diffuse large B-cell lymphoma comprises nearly 30% of non-Hodgkin lymphoma cases and patients with relapsed or refractory diffuse large B-cell lymphoma who are ineligible for stem-cell transplantation have few treatment options and poor prognoses. We aimed to determine whether the novel combination of polatuzumab vedotin in combination with rituximab and lenalidomide (Pola+R+Len) would provide a tolerable treatment option with enhanced antitumour response in patients with relapsed or refractory diffuse large B-cell lymphoma. METHODS This completed phase 1b/2, open-label, multicentre, single-arm study (GO29834) evaluated the safety and efficacy of Pola+R+Len in patients with relapsed or refractory diffuse large B-cell lymphoma at 19 sites in three countries (USA, Spain, and UK). Patients (≥18 years old) were eligible for inclusion if they had histologically documented CD20-positive relapsed or refractory diffuse large B-cell lymphoma and Eastern Cooperative Oncology Group performance status of 2 or lower, had received at least one previous line of chemoimmunotherapy, including an anti-CD20 agent, and were ineligible for stem-cell transplantation. The dose-escalation phase (1b) used escalating doses of lenalidomide to find the recommended phase 2 dose. Patients received six 28-day cycles of induction treatment with intravenous rituximab 375 mg/m2 and intravenous polatuzumab vedotin 1·8 mg/kg (all cohorts) plus oral lenalidomide at the following doses: 10 mg (cohort A); 15 mg (cohort B); and 20 mg (cohort C). Rituximab and polatuzumab vedotin were administered on day 1 and lenalidomide on days 1-21 of each 28-day cycle. During the dose-expansion phase (2), patients received six 28-day cycles of Pola+R+Len at the recommended phase 2 dose established during dose escalation. In both phases, patients with a complete response or partial response at the end of induction were eligible for post-induction therapy with rituximab 375 mg/m2 on day 1 and lenalidomide 10 mg/day on days 1-21 of each 28-day cycle for a maximum of 6 cycles. The primary safety objective of the dose-escalation phase was identification of the maximum tolerated dose through incidence of dose-limiting toxic effects. The primary efficacy outcome of the dose-expansion phase was Independent Review Committee-assessed complete response rate at end of induction, based on PET-CT. Analyses were conducted in the safety population, which included all patients who received at least one dose of any study drug, and the efficacy population, which included all patients who received at least one dose of any study drug at the recommended phase 2 dose. This study is registered with ClinicalTrials.gov, number NCT02600897. FINDINGS Between July 11, 2017 and Feb 3, 2020, 57 patients were enrolled (median age 71 years [IQR 60-75]; 38 [67%] were male and 19 (33%) were female; 47 [82%] were not Hispanic or Latino; and the median previous lines of therapy was 2 [IQR 1-3]). 18 participants were included in phase 1b and 39 were included in phase 2. Phase 1b confirmed a 20 mg recommended phase 2 dose for lenalidomide. After a median follow-up of 11·8 months (IQR 4·7-25·8), the complete response rate, as assessed by the Independent Review Committee, was 31% (90% CI 20-43). The most common grade 3-4 adverse events were neutropenia (35 [61%] of 57) and thrombocytopenia (eight [14%] of 57). Serious adverse events were reported in 23 (40%) of 57 patients and one patient died due to a treatment-related adverse event (neutropenic sepsis). INTERPRETATION Although the combination of Pola+R+Len did not meet the prespecified activity threshold, some patients derived clinical benefit and the regimen had a tolerable safety profile in patients with relapsed or refractory diffuse large B-cell lymphoma. FUNDING Genentech/F Hoffmann-La Roche.
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Affiliation(s)
| | - Eva González-Barca
- Insitut Català d'Oncologia, Hospital Duran I Reynals and IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Carlos Panizo
- Hospital Universitario Donostia, San Sebastián, Spain
| | | | - Fiona Miall
- Department of Haematology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mariana Bastos-Oreiro
- Hospital General Universitario Gregorio Marañón and Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Triguero
- Department of Haematology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Lalita Banerjee
- Oncology Centre, Maidstone and Tunbridge Wells NHS Trust, Kent, UK
| | - Andrew McMillan
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Erlene Seymour
- Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
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11
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Paciaroni K, Sangiorgi E, Pulvirenti F, Villiva N, Andrizzi C, Campagna S, Tordi A, Celesti F, Manna R, Gurrieri F, Licci S, di Toritto TC. Severe chronic primary neutropenia: findings from a patient who underwent exstensive evaluation including adenosine deaminase 2 gene variant assessment. Leuk Lymphoma 2023; 64:2343-2346. [PMID: 37698115 DOI: 10.1080/10428194.2023.2255912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Affiliation(s)
| | - Eugenio Sangiorgi
- Istituto di Medicina Genomica, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Pulvirenti
- Reference Centre for Primary Immune Deficiencies, Policlinico Umberto I, Rome, Italy
| | | | | | | | | | | | - Raffaele Manna
- Istituto di Medicina Interna, Rare diseases and periodic Fevers Research Center, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fiorella Gurrieri
- Operative Research Unit of Medical Genetics, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Stefano Licci
- Istituto di Medicina Interna, Rare diseases and periodic Fevers Research Center, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
- Pathology Unit, San Filippo Neri Hospital, Rome, Italy
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12
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Demirhan S, Munoz FM, Valencia Deray KG, Bocchini CE, Danziger-Isakov L, Blum S, Sharma TS, Sherman G, Boguniewicz J, Bacon S, Ardura MI, Maron GM, Ferrolino J, Foca M, Herold BC. Body surface area compared to body weight dosing of valganciclovir is associated with increased toxicity in pediatric solid organ transplantation recipients. Am J Transplant 2023; 23:1961-1971. [PMID: 37499799 DOI: 10.1016/j.ajt.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Optimal dosing of valganciclovir (VGCV) for cytomegalovirus (CMV) prevention in pediatric solid organ transplantation recipients (SOTR) is controversial. Dosing calculated based on body surface area (BSA) and creatinine clearance is recommended but simplified body weight (BW) dosing is often prescribed. We conducted a retrospective 6-center study to compare safety and efficacy of these strategies in the first-year posttransplant There were 100 (24.2%) pediatric SOTR treated with BSA and 312 (75.7%) with BW dosing. CMV DNAemia was documented in 31.0% vs 23.4% (P = .1) at any time during the first year and breakthrough DNAemia in 16% vs 12.2% (P = .3) of pediatric SOTR receiving BSA vs BW dosing, respectively. However, neutropenia (50% vs 29.3%, P <.001), lymphopenia (51% vs 15.0%, P <.001), and acute kidney injury causing treatment modification (8.0% vs 1.8%, P <.001) were documented more frequently during prophylaxis in pediatric SOTR receiving BSA vs BW dosing. The adjusted odds ratio of VGCV-attributed toxicities comparing BSA and BW dosing was 2.3 (95% confidence interval [CI], 1.4-3.7] for neutropenia, 7.0 (95% CI, 3.9-12.4) for lymphopenia, and 4.6 (95% CI, 2.2-9.3) for premature discontinuation or dose reduction of VGCV, respectively. Results demonstrate that BW dosing is associated with significantly less toxicity without any increase in CMV DNAemia.
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Affiliation(s)
- Salih Demirhan
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Flor M Munoz
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha Blum
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tanvi S Sharma
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilad Sherman
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha Bacon
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Monica I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Marc Foca
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Betsy C Herold
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
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13
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Küçükçongar Yavaş A, Engin Erdal A, Bilginer Gürbüz B, Ünlüsoy Aksu A, Kasapkara ÇS. Assessment of the diagnosis, treatment, and follow-up of a group of Turkish pediatric glycogen storage disease type 1b patients with varying clinical presentations and a novel mutation. J Pediatr Endocrinol Metab 2023; 36:1092-1099. [PMID: 37791580 DOI: 10.1515/jpem-2023-0336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVES Glycogen storage disease (GSD) type 1b is a multisystemic disease in which immune and infectious complications are present, different from GSD type 1a. Treatment with granulocyte-colony stimulating factor (G-CSF) is often required in the management of neutropenia and inflammatory bowel disease. Recently, an alternative treatment option to G-CSF has been preferred, like empagliflozin. To report on the demographics, genotype, clinical presentation, management, and complications of pediatric patients with glycogen storage disease type 1b (GSD 1b). METHODS A retrospective analysis of the clinical course of eight patients with GSD type 1b whose diagnosis was confirmed by molecular testing. RESULTS The mean age at referral was four months. The diagnosis of GSD 1b was based on clinical and laboratory findings and supported by genetic studies. One patient presented with an atypical clinical finding in the form of hydrocephalus at the time of first admission. The first symptom was abscess formation on the scalp due to neutropenia in another patient. Other patients had hypoglycemia at the time of admission. All patients presented suffered from neutropenia, which was managed with G-CSF, except one. Hospitalizations for infections were frequent. One patient developed chronic diarrhea and severe infections, which have been brought under control with empagliflozin. CONCLUSIONS Neutropenia is an essential finding in GSD 1b and responsible for complications. The coexistence of hypoglycemia and neutropenia should bring to mind GSD 1b. Empagliflozin can be a treatment option for neutropenia, which is resistant to G-CSF treatment.
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Affiliation(s)
- Aynur Küçükçongar Yavaş
- Department of Pediatric Metabolic Diseases, Children's Hospital, Ankara Bilkent City Hospital, Çankaya, Ankara, Türkiye
| | - Ayşenur Engin Erdal
- Department of Pediatric Metabolic Diseases, Children's Hospital, Ankara Bilkent City Hospital, Çankaya, Ankara, Türkiye
| | - Berrak Bilginer Gürbüz
- Department of Pediatric Metabolic Diseases, Children's Hospital, Ankara Bilkent City Hospital, Çankaya, Ankara, Türkiye
| | - Aysel Ünlüsoy Aksu
- Department of Pediatric Gastroenterology Diseases, Children's Hospital, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Çiğdem Seher Kasapkara
- Department of Pediatric Metabolic Diseases, Children's Hospital, Ankara Bilkent City Hospital, Çankaya, Ankara, Türkiye
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14
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Hoffman T, Atamna A, Litchevsky V, Amitai I, Yahav D. Fluoroquinolone Prophylaxis during Conventional Chemotherapy or Hematopoietic Stem Cell Transplantation for Acute Leukemia - Pros and Cons. Acta Haematol 2023; 147:186-197. [PMID: 37989116 DOI: 10.1159/000535119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Prophylaxis with fluoroquinolones (FQ) is commonly used in patients with acute leukemia (AL) during neutropenia. This practice is supported by an older meta-analysis reporting reduced mortality using FQ prophylaxis. Later meta-analyses have failed to reproduce this finding, presumably due to higher background FQ resistance rates limiting their effectiveness. SUMMARY This article reviews the pros and cons of FQ prophylaxis mainly in patients with AL. Most current guidelines do not support universal prophylaxis but rather recommend a selective approach, weighing the benefits against the risks. This recommendation is based on the lack of mortality benefit reported in more recent meta-analyses. FQ prophylaxis was demonstrated to reduce bacteremia and febrile neutropenia episodes, although mostly in trials performed in low-resistance settings (<20%), whereas current FQ resistance rates may reach 30-60%. Other disadvantages of FQ include potential adverse events, antibiotic resistance development, cost, increase in Gram-positive infections and resistant Gram-negative infections following prophylaxis, Clostridioides difficile infection, and an effect on gut microbiota. KEY MESSAGES Taking the above into consideration, alternative approaches other than universal FQ prophylaxis should be considered. Centers with high FQ resistance rates may consider either withholding prophylaxis or providing selective prophylaxis for high-risk patients screened negative for FQ-resistant bacteria.
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Affiliation(s)
- Tomer Hoffman
- Infectious Diseases Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | | | - Irina Amitai
- Hematology Division, Sheba Medical Center, Ramat Gan, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, Ramat Gan, Israel
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15
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Regev-Sadeh S, Borovitz Y, Steinberg-Shemer O, Gilad O, Shoham S, Yacobovich J. Cytopenias in pediatric kidney transplant recipients: preceding factors and clinical consequences. Pediatr Nephrol 2023; 38:3445-3454. [PMID: 37079102 DOI: 10.1007/s00467-023-05905-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Kidney trans plantation is associated with secondary complications, including the risk of developing posttransplant cytopenias. This study aimed to evaluate the characteristics, identify predictors, and assess the management and consequences of cytopenias in the pediatric kidney transplant population. METHODS This is a single-center retrospective analysis of 89 pediatric kidney transplant recipients. Possible factors preceding cytopenias were compared with the goal of recognizing predictors for posttransplant cytopenias. Posttransplant neutropenias were analyzed for the total study period and separately for the period beyond 6 months posttransplant (late neutropenias), to rule out confounding influences of induction and initial intensive therapy. RESULTS Sixty patients (67%) developed at least one episode of posttransplant cytopenia. All episodes of posttransplant thrombocytopenias were mild or moderate. Posttransplant infections and graft rejection were found to be significant predictors for thrombocytopenia (HR 6.06, 95% CI 1.6-22.9, and HR 5.82, 95% CI 1.27-26.6, respectively). A total of 30% of posttransplant neutropenias were severe (ANC ≤ 500). Pretransplant dialysis and posttransplant infections were significant predictors for late neutropenias (HR 11.2, 95% CI 1.45-86.4, and HR 3.32, 95% CI 1.46-7.57, respectively). Graft rejection occurred in 10% of patients with cytopenia, all following neutropenia, within 3 months from cytopenia appearance. In all such cases, mycophenolate mofetil dosing had been held or reduced prior to rejection. CONCLUSIONS Posttransplant infections are substantial contributors to developing posttransplant cytopenias. Preemptive transplantation appears to reduce risk of late neutropenia, the accompanying reduction in immunosuppressive therapy, and the ensuing risk of graft rejection. An alternative response to neutropenia, possibly using granulocyte colony stimulating factor, may diminish graft rejection. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
| | - Yael Borovitz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Nephrology Institute, Schneider Children's Medical Center, Petach Tikva, Israel.
| | - Orna Steinberg-Shemer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Oded Gilad
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Shoval Shoham
- Research Authority, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center, Petach Tikva, Israel
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16
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Martín García-Sancho A, Baile M, Rodríguez G, Dlouhy I, Sancho JM, Jarque I, González-Barca E, Salar A, Espeso M, Grande C, Bergua J, Montes-Moreno S, Redondo A, Enjuanes A, Campo E, López-Guillermo A, Caballero D. Lenalidomide in combination with R-ESHAP in patients with relapsed or refractory diffuse large B-cell lymphoma: A phase 2 study from GELTAMO. Br J Haematol 2023; 203:202-211. [PMID: 37485564 DOI: 10.1111/bjh.18989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/18/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) patients with relapsed or refractory (RR) disease have poor outcomes with current salvage regimens. We conducted a phase 2 trial to analyse the safety and efficacy of adding lenalidomide to R-ESHAP (LR-ESHAP) in patients with RR DLBCL. Subjects received 3 cycles of lenalidomide 10 mg/day on days 1-14 of every 21-day cycle, in combination with R-ESHAP at standard doses. Responding patients underwent autologous stem-cell transplantation (ASCT). The primary endpoint was the overall response rate (ORR) after 3 cycles. Centralized cell-of-origin (COO) classification was performed. Forty-six patients were included. The ORR after LR-ESHAP was 67% (35% of patients achieved complete remission). Patients with primary refractory disease (n = 26) had significantly worse ORR than patients with non-refractory disease (54% vs. 85%, p = 0.031). No differences in response rates according to the COO were observed. Twenty-eight patients (61%) underwent ASCT. At a median follow-up of 41 months, the estimated 3-year PFS and OS were 42% and 48%, respectively. The most common grade ≥3 adverse events were thrombocytopenia (70% of patients), neutropenia (67%) and anaemia (35%). There were no treatment-related deaths during LR-ESHAP cycles. In conclusion, LR-ESHAP is a feasible salvage regimen with promising efficacy results for patients with RR DLBCL.
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Affiliation(s)
- A Martín García-Sancho
- Hematology Department, Hospital Universitario de Salamanca-IBSAL, CIBERONC, Universidad de Salamanca, Salamanca, Spain
| | - M Baile
- Hematology Department, Hospital Universitario de Salamanca-IBSAL, CIBERONC, Universidad de Salamanca, Salamanca, Spain
| | - G Rodríguez
- Hematology Department, Hospital Universitario Virgen del Rocío/Virgen Macarena, Sevilla, Spain
| | - I Dlouhy
- Hematology Department, Hospital Clinic, Barcelona, Spain
| | - J M Sancho
- Hematology Department, Hospital Germans Trias i Pujol/ICO-IJC, Badalona, Spain
| | - I Jarque
- Hematology Department, Hospital Universitari i Plotècnic La Fe, CIBERONC, Valencia, Spain
| | - E González-Barca
- Institut Català d'Oncologia-Hospitalet, IDIBELL, Universitat de-Barcelona, Barcelona, Spain
| | - A Salar
- Hematology Department, Hospital del Mar, Barcelona, Spain
| | - M Espeso
- Hematology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - C Grande
- Hematology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J Bergua
- Hematology Department, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - S Montes-Moreno
- Pathology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - A Redondo
- Hematology Department, Hospital Virgen del Puerto, Plasencia, Spain
| | - A Enjuanes
- Unidad de Genómica del IDIBAPS, Barcelona, Spain
| | - E Campo
- Pathology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Caballero
- Hematology Department, Hospital Universitario de Salamanca-IBSAL, CIBERONC, Universidad de Salamanca, Salamanca, Spain
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17
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Zon RL, Berliner N. How I manage inpatient consultations for quantitative neutrophil abnormalities in adults. Blood 2023; 142:786-793. [PMID: 36279420 PMCID: PMC10562528 DOI: 10.1182/blood.2021014818] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/27/2022] [Accepted: 10/19/2022] [Indexed: 11/20/2022] Open
Abstract
Neutrophilia and neutropenia commonly lead to inpatient hematology consultation. Quantitative neutrophil abnormalities have a broad differential and include diagnoses that are important to recognize because they may be associated with increased mortality. Neutrophilia can reflect etiologies such as infection, medications, inflammation, splenectomy, and congenital disorders. Neutropenia can arise from infection, medications, autoimmune destruction, sequestration, nutritional deficiency, malignancy, and congenital neutropenia syndromes. In the evaluation of all abnormalities of neutrophil number, the timing of the change, and the patient's historical neutrophil count are crucial.
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Affiliation(s)
- Rebecca L. Zon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Nancy Berliner
- Divison of Hematology, Brigham and Women’s Hospital, Boston, MA
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Lazarow H, Compher C, Ziegler MJ, Gilmar C, Kucharczuk CR, Landsburg DJ. Central Line-Associated Bloodstream Infection in Patients With Hematologic Malignancy Receiving Parenteral Nutrition. JCO Oncol Pract 2023; 19:571-576. [PMID: 37200611 DOI: 10.1200/op.22.00823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/08/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023] Open
Abstract
PURPOSE Parenteral nutrition (PN) has been shown to be a safe method of feeding in the intensive care unit with modern infection prevention practices, but similar analysis in the hematology-oncology setting is lacking. METHODS A retrospective analysis of 1,617 patients with hematologic malignancies admitted and discharged from the Hospital of the University of Pennsylvania during 3,629 encounters from 2017 to 2019 was undertaken to evaluate the association of PN administration with risk of central line-associated bloodstream infection (CLABSI). Proportions of mucosal barrier injury (MBI)-CLABSI and non-MBI-CLABSI were also compared between groups. RESULTS Risk of CLABSI was associated with cancer type and duration of neutropenia but not with PN administration (odds ratio, 1.015; 95% CI, 0.986 to 1.045; P = .305) in a multivariable analysis. MBI-CLABSI comprised 73% of CLABSI in patients exposed to and 70% in patients not exposed to PN, and there was no significant difference between groups (χ2 = 0.06, P = .800). CONCLUSION PN was not associated with increased risk of CLABSI in a sample of patients with hematologic malignancy with central venous catheters when adjusting for cancer type, duration of neutropenia, and catheter days. The high proportion of MBI-CLABSI highlights the effect of gut permeability within this population.
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Affiliation(s)
- Heather Lazarow
- Hospital of the University of Pennsylvania, Philadelphia, PA
- Clinical Nutrition Support Services Silverstein 3, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Cheryl Gilmar
- Hospital of the University of Pennsylvania, Philadelphia, PA
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19
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Topf V, Kheifetz Y, Daum S, Ballhausen A, Schwarzer A, Trung KV, Stocker G, Aigner A, Lordick F, Scholz M, Knödler M. Individual hematotoxicity prediction of further chemotherapy cycles by dynamic mathematical models in patients with gastrointestinal tumors. J Cancer Res Clin Oncol 2023; 149:6989-6998. [PMID: 36854800 PMCID: PMC10374676 DOI: 10.1007/s00432-023-04601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/25/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Hematotoxicity is a common side-effect of cytotoxic gastrointestinal (GI) cancer therapies. An unsolved problem is to predict the individual risk therefore to decide on treatment adaptions. We applied an established biomathematical prediction model and primarily evaluated its predictive value in patients undergoing chemotherapy for GI cancers in curative intent. METHODS In a prospective, observational multicenter study on patients with gastro-esophageal or pancreatic cancer (n = 28) receiving myelosuppressive adjuvant or neoadjuvant chemotherapy (FLO(T) or FOLFIRINOX), individual model parameters were learned based on patients' observed laboratory values during the first chemotherapy cycle and further external data resources. Grades of hematotoxicity of subsequent cycles were predicted by model simulation and compared with observed data. RESULTS The most common high-grade hematological toxicity was neutropenia [19/28 patients (68%)]. For the FLO(T) regimen, individual grades of thrombocytopenia and leukopenia could be well predicted for cycles 2-4, as well as grades of neutropenia for cycle 2. Prediction accuracy for neutropenia in the third and fourth cycle differed by one toxicity grade on average. For the FOLFIRINOX-regimen, thrombocytopenia predictions showed a maximum deviation of one toxicity grade up to the end of therapy (8 cycles). Deviations of predictions were less than one degree on average up to cycle 4 for neutropenia, and up to cycle 6 for leukopenia. CONCLUSION The biomathematical model showed excellent short-term and decent long-term prediction performance for all relevant hematological side effects associated with FLO(T)/FOLFIRINOX. Clinical utility of this precision-medicine approach needs to be further investigated in a larger cohort.
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Affiliation(s)
- Vivien Topf
- University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectiology), Medical Center, University of Leipzig, Leipzig, Germany
| | - Yuri Kheifetz
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Severin Daum
- Medical Department, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité University Medicine Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
| | - Alexej Ballhausen
- Medical Department, Division of Hematology, Oncology and Tumor Immunology, Charité University Medicine Berlin, Campus Virchow Hospital (CVK), Berlin, Germany
| | | | - Kien Vu Trung
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectiology), Medical Center, University of Leipzig, Leipzig, Germany
| | - Gertraud Stocker
- University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectiology), Medical Center, University of Leipzig, Leipzig, Germany
| | - Achim Aigner
- Rudolf-Boehm-Institute for Pharmacology and Toxicology, Clinical Pharmacology, University of Leipzig, Leipzig, Germany
| | - Florian Lordick
- University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectiology), Medical Center, University of Leipzig, Leipzig, Germany
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Maren Knödler
- University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany.
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology and Infectiology), Medical Center, University of Leipzig, Leipzig, Germany.
- Charité Comprehensive Cancer Center (CCCC), Charité University Medicine Berlin, Campus Charité Mitte (CCM), Virchowweg 23, 10117, Berlin, Germany.
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20
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Mazahreh F, Mazahreh L, Schinke C, Thanendrarajan S, Zangari M, Shaughnessy JD, Zhan F, van Rhee F, Al Hadidi S. Risk of infections associated with the use of bispecific antibodies in multiple myeloma: a pooled analysis. Blood Adv 2023; 7:3069-3074. [PMID: 36857755 PMCID: PMC10331406 DOI: 10.1182/bloodadvances.2022009435] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
The use of bispecific antibodies (BsAbs) in the treatment of relapsed/refractory multiple myeloma (MM) is showing early promising overall response rates in heavily pretreated patients. Infectious complications related to the use of BsAbs are not well described. We conducted a pooled analysis that included all single-agent BsAbs used in MM with no prior use of different BsAbs. A total of 1185 patients with MM were treated with a BsAb in the studied period (71.6% of the patients treated with an agent targeting B-cell maturation antigen (BCMA). Pooled median follow-up was short at 6.1 months (7.5 vs 5.2 months for BCMA vs non-BCMA BsAbs, respectively). Adverse events of interest included all grade neutropenia in 38.6%, all grade infections in 50% (n = 542/1083), all grade cytokine release syndrome in 59.6% (n = 706/1185), grade III/IV neutropenia in 34.8% (n = 372/1068), grade III/IV infections in 24.5% (n = 272/1110), grade III/IV pneumonia in 10% (n = 52.4/506), and grade III/IV coronavirus disease 2019 in 11.4% (n = 45.4/395) of the patients. Non-BCMA-targeted BsAbs were associated with lower grade III/IV neutropenia (25.3% vs 39.2%) and lower grade III/IV infections (11.9% vs 30%) when compared with BCMA-targeted BsAbs. Hypogammaglobulinemia was reported in 4 studies, with a prevalence of 75.3% (n = 256/340) of the patients, with IV immunoglobulin used in 48% (n = 123/256) of them. Death was reported in 110 patients, of which 28 (25.5%) were reported to be secondary to infections. Certain precautions should be used when using BsAbs to mitigate the risk and/or identify and treat infections promptly.
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Affiliation(s)
- Farah Mazahreh
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - Carolina Schinke
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sharmilan Thanendrarajan
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Maurizio Zangari
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - John D. Shaughnessy
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Fenghuang Zhan
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Frits van Rhee
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Samer Al Hadidi
- Myeloma Institute, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
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Limaye AP, Budde K, Humar A, Vincenti F, Kuypers DRJ, Carroll RP, Stauffer N, Murata Y, Strizki JM, Teal VL, Gilbert CL, Haber BA. Letermovir vs Valganciclovir for Prophylaxis of Cytomegalovirus in High-Risk Kidney Transplant Recipients: A Randomized Clinical Trial. JAMA 2023; 330:33-42. [PMID: 37279999 PMCID: PMC10245286 DOI: 10.1001/jama.2023.9106] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
Importance Valganciclovir for 200 days is standard care for cytomegalovirus (CMV) prophylaxis in high-risk CMV-seronegative kidney transplant recipients who receive an organ from a CMV-seropositive donor, but its use is limited by myelosuppression. Objective To compare the efficacy and safety of letermovir with valganciclovir for prevention of CMV disease in CMV-seronegative kidney transplant recipients who receive an organ from a CMV-seropositive donor. Design, Setting, and Participants Randomized, double-masked, double-dummy, noninferiority, phase 3 trial in adult CMV-seronegative kidney transplant recipients who received an organ from a CMV-seropositive donor at 94 participating sites between May 2018 and April 2021 (final follow-up in April 2022). Interventions Participants were randomized in a 1:1 ratio (stratified by receipt of lymphocyte-depleting induction immunosuppression) to receive letermovir, 480 mg, orally daily (with acyclovir) or valganciclovir, 900 mg, orally daily (adjusted for kidney function) for up to 200 days after transplant, with matching placebos. Main Outcomes and Measures The primary outcome was CMV disease, confirmed by an independent masked adjudication committee, through posttransplant week 52 (prespecified noninferiority margin, 10%). CMV disease through week 28 and time to onset of CMV disease through week 52 were secondary outcomes. Exploratory outcomes included quantifiable CMV DNAemia and resistance. The rate of leukopenia or neutropenia through week 28 was a prespecified safety outcome. Results Among 601 participants randomized, 589 received at least 1 dose of the study drug (mean age, 49.6 years; 422 [71.6%] men). Letermovir (n = 289) was noninferior to valganciclovir (n = 297) for prevention of CMV disease through week 52 (10.4% vs 11.8% of participants with committee-confirmed CMV disease; stratum-adjusted difference -1.4% [95% CI, -6.5% to 3.8%]). No participants who received letermovir vs 5 participants (1.7%) who received valganciclovir developed CMV disease through week 28. Time to onset of CMV disease was comparable between the groups (hazard ratio, 0.90 [95% CI, 0.56-1.47]). Quantifiable CMV DNAemia was detected in 2.1% of participants in the letermovir group vs 8.8% in the valganciclovir group by week 28. Of participants evaluated for suspected CMV disease or CMV DNAemia, none (0/52) who received letermovir and 12.1% (8/66) who received valganciclovir had resistance-associated substitutions. The rate of leukopenia or neutropenia through week 28 was lower with letermovir vs valganciclovir (26% vs 64%; difference, -37.9% [95% CI, -45.1% to -30.3%]; P < .001). Fewer participants in the letermovir group than the valganciclovir group discontinued prophylaxis due to adverse events (4.1% vs 13.5%) or drug-related adverse events (2.7% vs 8.8%). Conclusion and Relevance Among adult CMV-seronegative kidney transplant recipients who received an organ from a CMV-seropositive donor, letermovir was noninferior to valganciclovir for prophylaxis of CMV disease over 52 weeks, with lower rates of leukopenia or neutropenia, supporting its use for this indication. Trial Registration ClinicalTrials.gov Identifier: NCT03443869; EudraCT: 2017-001055-30.
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Affiliation(s)
- Ajit P. Limaye
- Division of Allergy & Infectious Diseases, Departments of Medicine & Laboratory Medicine and Pathology, University of Washington Medicine, Seattle
| | | | - Atul Humar
- Ajmera Transplant Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Flavio Vincenti
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco
| | - Dirk R. J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, UZ Leuven, Leuven, Belgium
| | - Robert P. Carroll
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Takahari D, Katai H, Takashima A, Izawa N, Ishizuka N, Ohashi M, Mikami S, Wakatsuki T, Nakayama I, Chin K, Ida S, Kumagai K, Nunobe S, Iwasa S, Shoji H, Wada T, Doi A, Yoshikawa T, Sano T, Boku N, Yamaguchi K. Perioperative TAS-118 plus oxaliplatin in patients with locally advanced gastric cancer: APOLLO-11 study. Gastric Cancer 2023; 26:614-625. [PMID: 37029843 PMCID: PMC10285008 DOI: 10.1007/s10120-023-01388-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 03/27/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND We investigated the feasibility of perioperative chemotherapy with S-1 and leucovorin (TAS-118) plus oxaliplatin in patients with locally advanced gastric cancer. METHODS Patients with clinical T3-4N1-3M0 gastric cancer received four courses of TAS-118 (40-60 mg/body, orally, twice daily for seven days) plus oxaliplatin (85 mg/m2, intravenously, day one) every two weeks preoperatively followed by gastrectomy with D2 lymphadenectomy, followed by postoperative chemotherapy with either 12 courses of TAS-118 monotherapy (Step 1) or eight courses of TAS-118 plus oxaliplatin (Step 2). The primary endpoints were completion rates of preoperative chemotherapy with TAS-118 plus oxaliplatin and postoperative chemotherapy with TAS-118 monotherapy (Step 1) or TAS-118 plus oxaliplatin (Step 2). RESULTS Among 45 patients enrolled, the preoperative chemotherapy completion rate was 88.9% (90% CI 78.0-95.5). Major grade ≥ 3 adverse events (AEs) were diarrhoea (17.8%) and neutropenia (8.9%). The R0 resection rate was 95.6% (90% CI 86.7-99.2). Complete pathological response was achieved in 6 patients (13.3%). Dose-limiting toxicity was not observed in 31 patients receiving postoperative chemotherapy (Step 1, n = 11; Step 2, n = 20), and completion rates were 90.9% (95% CI 63.6-99.5) for Step 1 and 80.0% (95% CI 59.9-92.9) for Step 2. No more than 10% of grade ≥ 3 AEs were observed in patients receiving Step 1. Hypokalaemia and neutropenia occurred in 3 and 2 patients, respectively, receiving Step 2. The 3-year recurrence-free and overall survival rates were 66.7% (95% CI 50.9-78.4) and 84.4% (95% CI 70.1-92.3), respectively. CONCLUSIONS Perioperative chemotherapy with TAS-118 plus oxaliplatin with D2 gastrectomy is feasible.
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Affiliation(s)
- Daisuke Takahari
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Hitoshi Katai
- Department of Gastric Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Atsuo Takashima
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoki Izawa
- Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Naoki Ishizuka
- Department of Clinical Planning and Strategy, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinya Mikami
- Department of Gastrointestinal and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takeru Wakatsuki
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Izuma Nakayama
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Keisho Chin
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoru Iwasa
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hirokazu Shoji
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Takeyuki Wada
- Department of Gastric Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Ayako Doi
- Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takaki Yoshikawa
- Department of Gastric Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Narikazu Boku
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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23
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Loftus EV, Panés J, Lacerda AP, Peyrin-Biroulet L, D'Haens G, Panaccione R, Reinisch W, Louis E, Chen M, Nakase H, Begun J, Boland BS, Phillips C, Mohamed MEF, Liu J, Geng Z, Feng T, Dubcenco E, Colombel JF. Upadacitinib Induction and Maintenance Therapy for Crohn's Disease. N Engl J Med 2023; 388:1966-1980. [PMID: 37224198 DOI: 10.1056/nejmoa2212728] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Upadacitinib, an oral selective Janus kinase (JAK) inhibitor, is under investigation for the treatment of Crohn's disease. METHODS In two phase 3 induction trials (U-EXCEL and U-EXCEED), we randomly assigned patients with moderate-to-severe Crohn's disease to receive 45 mg of upadacitinib or placebo (2:1 ratio) once daily for 12 weeks. Patients who had a clinical response to upadacitinib induction therapy were randomly assigned in the U-ENDURE maintenance trial to receive 15 mg of upadacitinib, 30 mg of upadacitinib, or placebo (1:1:1 ratio) once daily for 52 weeks. The primary end points for induction (week 12) and maintenance (week 52) were clinical remission (defined as a Crohn's Disease Activity Index score of <150 [range, 0 to 600, with higher scores indicating more severe disease activity]) and endoscopic response (defined as a decrease in the Simple Endoscopic Score for Crohn's Disease [SES-CD; range, 0 to 56, with higher scores indicating more severe disease] of >50% from baseline of the induction trial [or for patients with an SES-CD of 4 at baseline, a decrease of ≥2 points from baseline]). RESULTS A total of 526 patients underwent randomization in U-EXCEL, 495 in U-EXCEED, and 502 in U-ENDURE. A significantly higher percentage of patients who received 45-mg upadacitinib than those who received placebo had clinical remission (in U-EXCEL, 49.5% vs. 29.1%; in U-EXCEED, 38.9% vs. 21.1%) and an endoscopic response (in U-EXCEL, 45.5% vs. 13.1%; in U-EXCEED, 34.6% vs. 3.5%) (P<0.001 for all comparisons). At week 52 in U-ENDURE, a higher percentage of patients had clinical remission with 15-mg upadacitinib (37.3%) or 30-mg upadacitinib (47.6%) than with placebo (15.1%), and a higher percentage had an endoscopic response with 15-mg upadacitinib (27.6%) or 30-mg upadacitinib (40.1%) than with placebo (7.3%) (P<0.001 for all comparisons). Herpes zoster infections occurred more frequently in the 45-mg and 30-mg upadacitinib groups than in the respective placebo groups, and hepatic disorders and neutropenia were more frequent in the 30-mg upadacitinib group than in the other maintenance groups. Gastrointestinal perforations developed in 4 patients who received 45-mg upadacitinib and in 1 patient each who received 30-mg or 15-mg upadacitinib. CONCLUSIONS Upadacitinib induction and maintenance treatment was superior to placebo in patients with moderate-to-severe Crohn's disease. (Funded by AbbVie; U-EXCEL, U-EXCEED, and U-ENDURE ClinicalTrials.gov numbers, NCT03345849, NCT03345836, and NCT03345823.).
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Affiliation(s)
- Edward V Loftus
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Julian Panés
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Ana P Lacerda
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Laurent Peyrin-Biroulet
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Geert D'Haens
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Remo Panaccione
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Walter Reinisch
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Edouard Louis
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Minhu Chen
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Hiroshi Nakase
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Jakob Begun
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Brigid S Boland
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Charles Phillips
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Mohamed-Eslam F Mohamed
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Jianzhong Liu
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Ziqian Geng
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Tian Feng
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Elena Dubcenco
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
| | - Jean-Frederic Colombel
- From the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN (E.V.L.); the Inflammatory Bowel Diseases Unit, Hospital Clinic Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona (J.P.); AbbVie, North Chicago, IL (A.P.L., C.P., M-E.F.M., J.L., Z.G., T.F., E.D.); the Department of Gastroenterology and INSERM Unité 1256, Nutrition-Genetics and Environmental Risk Exposure, Faculty of Medicine, University Hospital of Nancy, Lorraine University, Vandoeuvre, France (L.P.-B.); the Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam (G.D.); the Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada (R.P.); the Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna (W.R.); the Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital Centre Hospitalier Universitaire of Liège, Liège, Belgium (E.L.); the Division of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China (M.C.); the Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan (H.N.); the Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, QLD, Australia (J.B.); the Division of Gastroenterology, University of California, San Diego, La Jolla (B.B.); and the Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (J.-F.C.)
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Li W, Dong M, Huang S, Shi L, Yang H, Zhang Y, Gong J, Shi M, Wei L, Zhao L. Efficacy and safety of PEG-rhG-CSF in preventing chemoradiotherapy-induced neutropenia in patients with locally advanced cervical cancer. Bosn J Basic Med Sci 2023; 23:310-316. [PMID: 36300280 PMCID: PMC10113940 DOI: 10.17305/bjbms.2022.7859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/04/2022] [Indexed: 11/16/2022] Open
Abstract
The standard of care for locally advanced cervical cancer is concurrent chemoradiotherapy, which is associated with significant toxicity, especially hematologic toxicity. To evaluate the efficacy and safety of pegylated recombinant human granulocyte colony-stimulating factor (PEG-rhG-CSF) in preventing neutropenia during radical chemoradiotherapy for cervical cancer, 40 patients receiving prophylaxis from February 2018 to July 2019 were randomly divided into two arms in a 1:1 ratio. Patients in the study arm (N = 21) received PEG-rhG-CSF, while patients in the control arm (N = 19) received short-acting rhG-CSF. The primary endpoint was the incidence of grade 3-4 neutropenia, and the secondary endpoints were the incidence of febrile neutropenia, chemotherapy delay, and radiotherapy interruption. In addition, dynamic changes in absolute neutrophil count during radical chemoradiotherapy and adverse events were compared between the two groups. There were 0 and 4 cycles of grade 3-4 neutropenia in the PEG-rhG-CSF and rhG-CSF groups, respectively. The incidence of neutropenia of all grades was lower in patients on PEG-rhG-CSF than on rhG-CSF [24.05% (19/79) vs. 56.94% (41/72); p < 0.001]. No patient developed neutropenic fever. The lowest values of neutropenia during concurrent chemoradiotherapy cycles were 2.73 ± 1.02 and 1.91 ± 0.79 × 10 9/ml in the PEG-rhG-CSF and rhG-CSF groups, respectively (p < 0.001). In the PEG-rhG-CSF and rhG-CSF groups, 0 and 8 (11.11%) cycles of chemotherapy were delayed due to neutropenia, respectively (p = 0.01). There was no delay of radiotherapy by more than one week in either group. Prophylactic use of PEG-rhG-CSF during chemoradiotherapy for cervical cancer can effectively prevent neutropenia and associated adverse events. PEG-rhG-CSF may be an effective strategy to provide uninterrupted radical chemoradiotherapy for cervical cancer.
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Affiliation(s)
- Weiwei Li
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Mohan Dong
- Department of Medical Education, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Shigao Huang
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Liu Shi
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Hua Yang
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Ying Zhang
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Jie Gong
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Mei Shi
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Lichun Wei
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
| | - Lina Zhao
- Department of Radiation Oncology, The First Affiliated Hospital, Air Force Medical University, Xi an, China
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Brabrand M, Brabrand M, Bogh SB, Fløjstrup M, Frederiksen H. The incidence and mortality of neutropenic fever in hematologic patients did not change during the SARS-CoV2 pandemic. Acute Med 2023; 22:201-203. [PMID: 38284635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
During the current SARS-CoV2 pandemic, fear of nosocomial infection could keep neutropenic patients from contacting the healthcare system with infection. We analyzed nationwide hospital contacts for neutropenic fever during the first seven weeks of the Danish shelter at home order. Using national registers, we extracted data on all unplanned hospital contacts due to neutropenic fever. We included 311 admissions, 13-30 per week, and found no difference between 2017-2019 and 2020. The incidence rate ratio varied between 0.68 and 1.11 with no effect on mortality. Thus, our data indicate that Danish neutropenic patients are admitted with fever, even during a pandemic.
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Affiliation(s)
- M Brabrand
- Department of Hematology, Odense University Hospital, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark. Instutute of Regional Health Research, University of Southern Denmark, Denmark. Department of Emergency Medicine, Odense University Hospital, Denmark
| | - S B Bogh
- OPEN, University of Southern Denmark, Denmark
| | - M Fløjstrup
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark. Instutute of Regional Health Research, University of Southern Denmark, Denmark
| | - H Frederiksen
- Department of Hematology, Odense University Hospital, Denmark, Institute of Clinical Research, University of Southern Denmark, Denmark
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Tomita K, Tokugawa S, Inui G, Moriyasu S, Ikeuchi T, Touge H, Tajima F. Granulocyte-colony-stimulating Factor-resistant Neutropenia and Polyneuropathy Presenting as Severe Complications of Sjögren's Syndrome. Intern Med 2022; 61:3287-3291. [PMID: 35342136 PMCID: PMC9683808 DOI: 10.2169/internalmedicine.9092-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) has multi-dimensional manifestations, including neutropenia and polyneuropathy. We herein report a 76-year-old woman with pSS initially presenting as severe granulocyte-colony-stimulating factor (G-CSF)-refractory neutropenia and axonal sensorimotor polyneuropathies (SMP). Systemic glucocorticoid administration had reduced neutrophil-associated immunoglobulin G (NAIgG) on the neutrophil surface as detected using flow cytometry, resulting in the development of neutropenia. A patient with pSS concomitant with axonal SMP might show severe neutropenia as aggressive autoimmune disease. Neutropenia can be treated with systemic glucocorticoids based on the assessment of NAIgG on the neutrophil surface.
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Affiliation(s)
- Katsuyuki Tomita
- Department of Respiratory Medicine, National Hospital Organization Yonago Medical Center, Japan
| | - Shinnosuke Tokugawa
- Center for Clinical Residency Program, National Hospital Organization Yonago Medical Center, Japan
| | - Genki Inui
- Department of Respiratory Medicine, National Hospital Organization Yonago Medical Center, Japan
| | - Shotaro Moriyasu
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Japan
| | - Tomoyuki Ikeuchi
- Department of Respiratory Medicine, National Hospital Organization Yonago Medical Center, Japan
| | - Hirokazu Touge
- Department of Respiratory Medicine, National Hospital Organization Yonago Medical Center, Japan
| | - Fuminari Tajima
- Department of Hematology and Oncology, National Hospital Organization Yonago Medical Center, Japan
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Breast Cancer Group, Branch of Oncologist, Chinese Medical Doctor Association;, International Medical Exchange Society, Chinese Anti-Cancer Association. [Chinese expert consensus of antibody-drug conjugate toxicity management for breast cancer]. Zhonghua Zhong Liu Za Zhi 2022; 44:913-27. [PMID: 36164692 DOI: 10.3760/cma.j.cn112152-20220521-00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
As a newly emerged class of anticancer bioagents in the most precise and selectively targeted way, antibody-drug conjugate (ADC) combines the cancer-targeting abilities of monoclonal antibodies with the cytotoxicity potency of payload, delivering highly cytotoxic drug into tumors via 'targeted chemotherapy'. ADC has revolutionized the treatment landscape of human epidermal growth factor receptor 2 positive and triple negative subtypes in breast cancer. Three ADCs have been approved by U. S. Food and Drug Administration with breast cancer indications, including trastuzumab emtansine (T-DM1; also approved in China), trastuzumab deruxtecan (T-DXd, DS-8201) and sacituzumab govitecan (IMMU-132; also approved in China). Antibodies, cytotoxic drug, linker, and conjugation process are implicated in ADC profile, resulting in unique adverse drug reactions and toxicity heterogeneity within ADC class. For example, more attention should be paid to the management of thrombocytopenia, hepatotoxicity, and reductions in left ventricular ejection fraction (LVEF) in patients treated with trastuzumab emtansine; clinical physicians should pay attention to the risk of neutropenia, interstitial lung disease/pneumonitis, and reductions in LVEF when treated with trastuzumab deruxtecan; sacituzumab govitecan most frequently caused neutropenia, anemia and diarrhea requiring close monitor. ADC has generally favorable safety profiles, and dose modifications and/or symptomatic supporting treatment are effective in terms of toxicity management. This consensus aims at providing guidance for clinical oncologists of early detection, regular assessment, timely management and follow-up monitor of ADC-associated adverse reactions/events.
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Abstract
Autosomal dominant mutations in the signal recognition particle (SRP) 54 gene were recently described in patients with severe congenital neutropenia (SCN). SRP54 deficiency cause a chronic and profound neutropenia with maturation arrest at the promyelocyte stage, occurring in the first months of life. Nearly all reported patients with SRP54 mutations had neutropenia without a cyclic pattern and showed a poor or no response to granulocyte colony-stimulating factor (G-CSF) therapy. We report here an 11-year-old female patient with cyclic neutropenia and recurrent heterozygous p.T117del (c.349_351del) in-frame deletion mutation in SRP54, who showed remarkable therapeutic response to G-CSF treatment. The diagnosis of cyclic pattern of neutropenia was established by acceptable standards. ELANE gene mutation was excluded by using various genetic approaches. The patient described here also had dolichocolon which has not been described before in association with SCN.
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Affiliation(s)
- Melinda Erdős
- Primary Immunodeficiency Clinical Unit and Laboratory, Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University, New York, NY, United States
| | - Oksana Boyarchuk
- Department of Children’s Diseases and Pediatric Surgery, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - László Maródi
- Primary Immunodeficiency Clinical Unit and Laboratory, Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University, New York, NY, United States
- *Correspondence: László Maródi,
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Abstract
IMPORTANCE Myelodysplastic neoplasms (MDS), formerly known as myelodysplastic syndromes, are clonal hematopoietic malignancies that cause morphologic bone marrow dysplasia along with anemia, neutropenia, or thrombocytopenia. MDS are associated with an increased risk of acute myeloid leukemia (AML). The yearly incidence of MDS is approximately 4 per 100 000 people in the United States and is higher among patients with advanced age. OBSERVATIONS MDS are characterized by reduced numbers of peripheral blood cells, an increased risk of acute myeloid leukemia transformation, and reduced survival. The median age at diagnosis is approximately 70 years, and the yearly incidence rate increases to 25 per 100 000 in people aged 65 years and older. Risk factors associated with MDS include older age and prior exposures to toxins such as chemotherapy or radiation therapy. MDS are more common in men compared with women (with yearly incidence rates of approximately 5.4 vs 2.9 per 100 000). MDS typically has an insidious presentation, consisting of signs and symptoms associated with anemia, thrombocytopenia, and neutropenia. MDS can be categorized into subtypes that are associated with lower or higher risk for acute myeloid leukemia transformation and that help with therapy selection. Patients with lower-risk MDS have a median survival of approximately 3 to 10 years, whereas patients with higher-risk disease have a median survival of less than 3 years. Therapy for lower-risk MDS is selected based on whether the primary clinical characteristic is anemia, thrombocytopenia, or neutropenia. Management focuses on treating symptoms and reducing the number of required transfusions in patients with low-risk disease. For patients with lower-risk MDS, erythropoiesis stimulating agents, such as recombinant humanized erythropoietin or the longer-acting erythropoietin, darbepoetin alfa, can improve anemia in 15% to 40% of patients for a median of 8 to 23 months. For those with higher-risk MDS, hypomethylating agents such as azacitidine, decitabine, or decitabine/cedazuridine are first-line therapy. Hematopoietic cell transplantation is considered for higher-risk patients and represents the only potential cure. CONCLUSIONS AND RELEVANCE MDS are diagnosed in approximately 4 per 100 000 people in the United States and are associated with a 5-year survival rate of approximately 37%. Treatments are tailored to the patient's disease characteristics and comorbidities and range from supportive care with or without erythropoiesis-stimulating agents for patients with low-risk MDS to hypomethylating agents, such as azacitidine or decitabine, for patients with higher-risk MDS. Hematopoietic cell transplantation is potentially curative and should be considered for patients with higher-risk MDS at the time of diagnosis.
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Affiliation(s)
- Mikkael A Sekeres
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Justin Taylor
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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Zhou J, Zhang Y, Shan M, Zong X, Geng H, Li J, Chen G, Yu L, Xu Y, Li C, Wu D. Cytopenia after chimeric antigen receptor T cell immunotherapy in relapsed or refractory lymphoma. Front Immunol 2022; 13:997589. [PMID: 36131934 PMCID: PMC9484486 DOI: 10.3389/fimmu.2022.997589] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients with relapsed or refractory (R/R) lymphomas have benefited from chimeric antigen receptor (CAR)-T-cell therapy. However, this treatment is linked to a high frequency of adverse events (AEs), such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematologic toxicity. There has been increasing interest in hematological toxicity in recent years, as it can result in additional complications, such as infection or hemorrhage, which remain intractable. Methods We conducted a retrospective, single-institution study to evaluate the patterns and outcomes of cytopenia following CAR-T-cell infusion and potential associated factors. Results Overall, 133 patients with R/R lymphoma who received CAR-T-cell therapy from June, 2017 to April, 2022 were included in this analysis. Severe neutropenia, anemia and thrombocytopenia occurred frequently (71, 30 and 41%, respectively) after CAR-T-cell infusion. A total of 98% of severe neutropenia and all severe thrombocytopenia cases occurred in the early phase. Early severe cytopenia was associated with CRS incidence and severity, as well as peak inflammatory factor (IL-6, C-reactive protein (CRP), and ferritin) levels. In multivariate analysis, prior hematopoietic stem cell transplantation (HSCT), baseline hemoglobin (HB), and lymphodepleting chemotherapy were independent adverse factors associated with early severe cytopenia. In addition, 18% and 35% of patients had late neutrophil- and platelet (PLT)-related toxicity, respectively. In multivariate analysis, lower baseline PLT count was an independent factor associated with late thrombocytopenia. More severe cytopenia was associated with higher infection rates and poorer survival. Conclusions This research indicates that improved selection of patients and management of CRS may help to decrease the severity of cytopenias and associated AEs and improve survival following CAR-T-cell therapy. Clinical Trial Registration https://www.clinicaltrials.gov/ct2/show/NCT03196830, identifier NCT03196830.
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Affiliation(s)
- Jin Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Ying Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Meng Shan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Xiangping Zong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Hongzhi Geng
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Jiaqi Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Guanghua Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
| | - Lei Yu
- Institute of Biomedical Engineering and Technology, Shanghai Engineering Research Center of Molecular Therapeutics and New Drug Development, School of Chemistry and Molecular Engineering, East China Normal University, Shanghai, China
| | - Yang Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
| | - Caixia Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- Key Laboratory of Stem Cells and Biomedical Materials of Jiangsu Province and Chinese Ministry of Science and Technology, Suzhou, China
- *Correspondence: Depei Wu, ; Caixia Li, ; Yang Xu,
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Lee MY, Chang YJ, Lu YC, Kuo CH, Kuo YH, Tzeng SC, Hsu GJ. Rapid Administration of Antibiotics for Reducing Fever Days in Patients Receiving Hematopoietic Stem Cell Transplantation. Medicina (Kaunas) 2022; 58:medicina58091157. [PMID: 36143836 PMCID: PMC9501244 DOI: 10.3390/medicina58091157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/10/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Neutropenic fever (NF) is a major cause of mortality and morbidity in patients undergoing hematopoietic stem cell transplantation (HSCT). To date, no study has discussed the relationship of fever days in HSCT with the time between recording the fever and administering antibiotics. This study aimed to examine the association between fever days in HSCT and the time interval between recording the fever and intravenous (IV) antibiotics to the febrile neutropenia patient. Materials and Methods: A total of 22 patients who developed NF after HSCT in one hospital were analyzed. Patients who received IV antibiotics injection within 30 min were categorized in group A and those who received the injection after 30 min were categorized in group B. Fever was defined by an attack with an oral temperature of 38.3 °C. Patients’ characteristics and possible risk factors were recorded and analyzed. Results: Groups A and B had 14 and 8 patients, respectively. Patient characteristics, including age, diagnosis, sex, and antibiotics level, were similar between the two groups. The median duration of fever days was 1.5 (range, 1−5) in group A and 6.5 (range, 1−14) in group B (p = 0.003). Multivariant analysis of possible independent impact factors of “fever days in HSCT” was performed. The odds ratio of “antibiotics given time” was 4.00 (95% confidence interval [CI] = 2.26 to 7.22, p = 0.001). The “antibiotics level” did not affect the NF period (odds ratio = −0.80, 95% CI = −2.40 to 1.07, p = 0.453). Conclusions: Rapid IV administration of antibiotics (<30 min after fever attack) can reduce the fever days in patients undergoing HSCT.
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Affiliation(s)
- Ming-Yang Lee
- Division of Hemato-Oncology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
- Min-Hwei Junior College of Health Care Management, Tainan 73658, Taiwan
- Correspondence: ; Tel.: +886-5-2765041
| | - Yu-Ju Chang
- Department of Nursing Care, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
| | - Yin-Che Lu
- Division of Hemato-Oncology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
- Min-Hwei Junior College of Health Care Management, Tainan 73658, Taiwan
| | - Chin-Ho Kuo
- Division of Hemato-Oncology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
- Min-Hwei Junior College of Health Care Management, Tainan 73658, Taiwan
| | - Ya-Hui Kuo
- Department of Nursing Care, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
| | - Shu-Chien Tzeng
- Department of Nursing Care, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
| | - Gwo-Jong Hsu
- Division of Infection, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi 60002, Taiwan
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Faierstein K, Shilo N, Levartovsky A, Raphael R, Givon A, Agmon-Levin N, Mayan H. Autoimmune Neutropenia Associated With HHV-6 Virus Infection: A Case Report. Front Immunol 2022; 13:880016. [PMID: 35615353 PMCID: PMC9124847 DOI: 10.3389/fimmu.2022.880016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Autoimmune neutropenia (AIN) is divided into primary and secondary forms. The former is more prevalent in children and is usually a self-limiting disease. Secondary AIN is more common in adults and often occurs in the setting of another autoimmune disorder or secondary to infections, malignancies or medications. Several viral and bacterial pathogens were described to trigger AIN. Here we report a case of AIN in an adult woman associated with human herpesvirus-6 (HHV-6) infection. Case Presentation We report a case of AIN in an adult woman associated with HHV-6 infection. The patient presented to the emergency department with fever and painful genital ulcers. Upon arrival, her laboratory workup demonstrated severe neutropenia and elevated inflammatory markers. She was hospitalized and underwent a thorough infectious, hematological, autoimmune and inflammatory workup. Malignancy was also excluded using an advanced whole body radiological scan. Serological tests confirmed the presence of both acute and chronic types of HHV-6 antibodies, at very high titers. Polymerase chain reaction demonstrated a numerous copies of the virus in the patient’s blood. Specific immunofluorescence test confirmed the diagnosis of autoimmune neutropenia. Conclusion Secondary AIN is a rare disease that may affect all range of ages. The adult type is a challenging disorder that has different etiologies and may be triggered by a variable infectious pathogen. The finding of HHV-6 as a possible culprit pathogen may warrant physicians into widening the evaluation and include HHV-6 in the analysis.
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Affiliation(s)
- Kobi Faierstein
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Kobi Faierstein,
| | - Noya Shilo
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Levartovsky
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Raphael
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Givon
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Agmon-Levin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Haim Mayan
- Department of Medicine E, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Irie S, Matsumoto S. Transient severe neutropenia in an infant with SARS-CoV-2 infection. Pediatr Neonatol 2022; 63:324-325. [PMID: 35283056 PMCID: PMC8881219 DOI: 10.1016/j.pedneo.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 01/08/2023] Open
Affiliation(s)
- Shinji Irie
- Department of Pediatrics, National Hospital Organization Miyakonojo Medical Center, Miyakonojo, Miyazaki, Japan.
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
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Jarasvaraparn C, Choudhury S, Rusch C, Nadler M, Liss KH, Stoll J, Hmiel S, Khan A, Doyle M, Kulkarni S. Characteristics, risk factors, and outcomes of neutropenia after liver or kidney transplantation in children. Pediatr Transplant 2022; 26:e14131. [PMID: 34494348 PMCID: PMC10591294 DOI: 10.1111/petr.14131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND While prior adult studies have shown that approximately 20%-38% of subjects undergoing solid-organ transplant develop neutropenia, similar analyses in pediatric subjects are scarce. METHODS We conducted a retrospective chart review of liver transplant (LT) and kidney transplant (KT) recipients at our center during the period 2008-2018. All of the KT and none of the LT subjects during this time period had induction with either anti-thymocyte globulin (ATG) or basiliximab at time of transplant. Neutropenia was defined as absolute neutrophil count (ANC) value ≤1000/mm3 . RESULTS One hundred subjects with LT and 82 subjects with KT were included. The incidence of neutropenia within the first year of transplant in KT was higher compared to LT (54.8% vs 39%, p = .01). The median number of hospitalizations (p = .001) and infectious complications (p = .04) was significantly higher only in the KT subjects who developed neutropenia (compared to those who did not). Multivariate analysis identified factors associated with severity of liver disease at transplant, namely h/o upper gastrointestinal bleeding (p = .02), weight deficit (p = .01), and pre-LT ANC (p = .01), along with high or moderate risk cytomegalovirus status (p = .05) as predictors of neutropenia in LT subjects. Female gender (p = .03) predicted neutropenia, while BK virus infection was protective for neutropenia (p = .04) in KT subjects. CONCLUSIONS The incidence of and morbidity associated with neutropenia within 1 year post-transplant is higher in KT subjects compared to LT subjects. The likely reason for this is the use of induction therapy (ATG, basiliximab) at the time of transplant in KT subjects.
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Affiliation(s)
- Chaowapong Jarasvaraparn
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shelley Choudhury
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Courtney Rusch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michelle Nadler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kim H.H. Liss
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stanley Hmiel
- Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adeel Khan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maria Doyle
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sakil Kulkarni
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
As a key member of the innate and adaptive immune response, neutrophils provide insights into the hematopoietic and inflammatory manifestations of inborn errors of immunity (IEI) and the consequences of immunotherapy. The facile recognition of IEI presenting with neutropenia provides an avenue for hematologists to facilitate early diagnosis and expedite biologically rationale care. Moreover, enhancing the understanding of the molecular mechanisms driving neutropenia in IEI-decreased bone marrow reserves, diminished egress from the bone marrow, and decreased survival-offers an opportunity to further dissect the pathophysiology driving neutropenia secondary to iatrogenic immune dysregulation, eg, immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy.
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Affiliation(s)
- Kelly Walkovich
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
- Correspondence Kelly Walkovich, Department of Pediatrics, University of Michigan, 1540 E Medical Center Dr, Ann Arbor, MI 48109; e-mail:
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Pulcini CD, Lentz S, Saladino RA, Bounds R, Herrington R, Michaels MG, Maurer SH. Emergency management of fever and neutropenia in children with cancer: A review. Am J Emerg Med 2021; 50:693-698. [PMID: 34879488 DOI: 10.1016/j.ajem.2021.09.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery and Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine and Critical Care, Department of Surgery and Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States of America
| | - Richard A Saladino
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Richard Bounds
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Ramsey Herrington
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| | - Marian G Michaels
- Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Scott H Maurer
- Division of Hematology/Oncology, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
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White MG, Morgan RB, Drazer MW, Eng OS. Gastrointestinal Surgical Emergencies in the Neutropenic Immunocompromised Patient. J Gastrointest Surg 2021; 25:3258-3264. [PMID: 34506017 PMCID: PMC8665083 DOI: 10.1007/s11605-021-05116-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/03/2021] [Indexed: 01/31/2023]
Abstract
Surgeons encounter neutropenic patients through elective or emergency consultation with increasing regularity. As medical management continues to extend the lives of patients with benign hematologic diseases, hematologic malignancies, solid malignancies, or iatrogenic neutropenia, more patients are presenting with infectious complications caused and/or complicated by their neutropenia. This leaves surgeons in the difficult position of managing medically fragile patients with unusual presentations of common disease processes. These patients often fall outside of classical guidelines and treatment pathways. Many studies addressing these issues are retrospective and non-randomized. Here, we review common emergency gastrointestinal surgery scenarios and their management in the setting of a neutropenic patient. While biliary disease, appendicitis, anorectal disease, and perforations will be covered in detail, an extensive appreciation of a patient's medical or oncologic disease course and appropriate utilization of consultants such as interventional radiology, gastroenterology, and hematology is often necessary.
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Affiliation(s)
- Michael G White
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan B Morgan
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA
| | - Michael W Drazer
- Department of Medicine and Human Genetics, Section of Hematology and Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA
| | - Oliver S Eng
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago, 5841 S. Maryland Ave, G 205, MC 5094, Chicago, IL, 60637, USA.
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Bandura A, Kurlapski M, Kamińska M, Dziadziuszko R, Jassem J. Profound neutropenia related to consolidation durvalumab following concurrent radiochemotherapy in III stage non-small-cell lung cancer patient. Pol Arch Intern Med 2021; 132. [PMID: 34851079 DOI: 10.20452/pamw.16161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Artur Bandura
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdańsk, Poland.
| | - Michał Kurlapski
- Department of Hematology, Medical University of Gdansk, Gdańsk, Poland
| | | | - Rafał Dziadziuszko
- Early Clinical Trials Center, Medical University of Gdansk, Gdańsk, Poland
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdańsk, Poland
| | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdańsk, Poland
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de Almeida-Neto C, Corso LM, Bassolli L, Witkin SS, Hamasaki DT, Albiero AL, Manangão CL, Mendrone-Junior A, Rocha V. Survival among children and adults treated with granulocyte transfusions: Twenty years' experience at a Brazilian blood center. Transfus Apher Sci 2021; 61:103300. [PMID: 34756651 DOI: 10.1016/j.transci.2021.103300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 10/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND It remains controversial whether granulocyte transfusions as a supportive treatment improve survival in patients with febrile neutropenia or granulocyte dysfunctions. We describe survival rates subsequent to granulocyte transfusions in pediatric and adults patients treated at a major blood center in Brazil. MATERIAL AND METHODS We retrospectively reviewed the clinical charts of pediatric and adult patients treated with granulocyte transfusions at our institution from January 2000 to October 2019. We assessed demographic characteristics, clinical features, indications for transfusion, units transfused, dose of granulocytes administered and survival rates 30 and 100 days after the initial transfusion. RESULTS We identified 64 pediatric and 67 adult patients treated with 262 granulocyte transfusions. An optimal dose (> 0.6 × 109 granulocytes per kilogram per transfused unit) was available for transfusion in 80.4 % of pediatric patients but in only 19.6 % of adults (p = 0.017). Thirty days after their first granulocyte transfusion, 38 (59.4 %) pediatric and 61 (91 %) adult patients had died. Patients receiving the optimal dose of granulocytes had better survival outcomes, but even among this sub-group, adults were more likely to die than were children either at 30 days (OR = 8.67, 95 %CI 2.69-34.9) or 100 days (OR = 6.27, 95 %CI 1.86-25.9) after their initial granulocyte transfusion. CONCLUSION Survival rates following granulocyte transfusion varied by the dose transfused and were higher in children than in adults.
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Affiliation(s)
- Cesar de Almeida-Neto
- Fundação Pró-Sangue - Hemocentro de São Paulo, São Paulo, SP, Brazil; Disciplina de Hematologia, Hemoterapia e Terapia Celular da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Disciplina de Ciências Médicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Lucas Machado Corso
- Disciplina de Hematologia, Hemoterapia e Terapia Celular da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Lucas Bassolli
- Disciplina de Hematologia, Hemoterapia e Terapia Celular da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Laboratório de Investigação Médica 31 (LIM-31) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Steven S Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, USA; Institute of Tropical Medicine, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Debora Toshie Hamasaki
- Fundação Pró-Sangue - Hemocentro de São Paulo, São Paulo, SP, Brazil; Disciplina de Hematologia, Hemoterapia e Terapia Celular da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Caroline Limoeiro Manangão
- Fundação Pró-Sangue - Hemocentro de São Paulo, São Paulo, SP, Brazil; Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Tratamento do Câncer Infantil, São Paulo, Brazil
| | - Alfredo Mendrone-Junior
- Fundação Pró-Sangue - Hemocentro de São Paulo, São Paulo, SP, Brazil; Laboratório de Investigação Médica 31 (LIM-31) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Fundação Pró-Sangue - Hemocentro de São Paulo, São Paulo, SP, Brazil; Disciplina de Hematologia, Hemoterapia e Terapia Celular da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Laboratório de Investigação Médica 31 (LIM-31) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Getz KD, Szymczak JE, Li Y, Madding R, Huang YSV, Aftandilian C, Arnold SD, Bona KO, Caywood E, Collier AB, Gramatges MM, Henry M, Lotterman C, Maloney K, Mian A, Mody R, Morgan E, Raetz EA, Rubnitz J, Verma A, Winick N, Wilkes JJ, Yu JC, Fisher BT, Aplenc R. Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia. JAMA Netw Open 2021; 4:e2128385. [PMID: 34709389 PMCID: PMC8554641 DOI: 10.1001/jamanetworkopen.2021.28385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVE To evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTS This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTS Primary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7] days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7 [19.4]; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6). A total of 86 respondents (20 [23.3%] in outpatient management, 66 [76.7%] in inpatient management) completed qualitative interviews. Independent of management strategy received, 74 respondents (86.0%) expressed satisfaction with their experience. Concerns for hospital-associated infections among caregivers (6 of 7 caregiver respondents [85.7%] who were dissatisfied with inpatient management) and family separation (2 of 2 patient respondents [100%] who were dissatisfied with inpatient management) drove dissatisfaction with inpatient management. Stress of caring for a neutropenic child at home (3 of 3 respondents [100%] who were dissatisfied with outpatient management) drove dissatisfaction with outpatient management. CONCLUSIONS AND RELEVANCE This cohort study found that outpatient neutropenia management was not associated with higher bacteremia incidence, treatment delays, or worse HRQOL compared with inpatient neutropenia management among pediatric patients with AML. While outpatient management may be safe for many patients, course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution. Patient and family experiences varied, suggesting that outpatient management may be preferred by some but may not be feasible for all families. Further studies to refine and standardize safe outpatient management practices are warranted.
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Affiliation(s)
- Kelly D. Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Madding
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yuan-Shung V. Huang
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Aftandilian
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Stanford University, Palo Alto, California
| | - Staci D. Arnold
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Kira O. Bona
- Pediatric Hematology/Oncology, Children’s Hospital Boston, Boston, Massachusetts
| | - Emi Caywood
- A.I. Dupont Hospital for Children, Nemours, Wilmington, Delaware
| | | | | | | | | | - Kelly Maloney
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Amir Mian
- Arkansas Children’s Hospital, Little Rock
| | | | - Elaine Morgan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth A. Raetz
- Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, New York, New York
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City
| | - Naomi Winick
- Department of Pediatric Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer J. Wilkes
- Department of Pediatrics, University of Washington, Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle
| | - Jennifer C. Yu
- Division of Pediatric Hematology Oncology, Rady Children’s Hospital San Diego, San Diego, California
| | - Brian T. Fisher
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Wei J, Wu M, Liu J, Wang X, Yang H, Xia P, Peng L, Huang Y, Liu C, Xia Z, Chen C, Zhao Y. Characteristics and outcomes of COVID-19 infection in 45 patients with breast cancer: A multi-center retrospective study in Hubei, China. Breast 2021; 59:102-109. [PMID: 34225090 PMCID: PMC8233853 DOI: 10.1016/j.breast.2021.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic is a significant worldwide health crisis. Breast cancer patients with COVID-19 are fragile and require particular clinical care. This study aimed to identify the clinical characteristics of breast cancer patients with COVID-19 and the risks associated with anti-cancer treatment. METHODS The medical records of breast cancer patients with laboratory-confirmed COVID-19 were collected among 9559 COVID-19 patients from seven designated hospitals from 13th January to 18th March 2020 in Hubei, China. Univariate and multivariate analyses were performed to assess risk factors for COVID-19 severity. RESULTS Of the 45 breast cancer patients with COVID-19, 33 (73.3%) developed non-severe COVID-19, while 12 (26.7%) developed severe COVID-19, of which 3 (6.7%) patients died. The median age was 62 years, and 3 (6.7%) patients had stage IV breast cancer. Univariate analysis showed that age over 75 and the Eastern Cooperative Oncology Group (ECOG) score were associated with COVID-19 disease severity (P < 0.05). Multivariate analysis showed that patients who received chemotherapy within 7 days had a significantly higher risk for severe COVID-19 (logistic regression model: RR = 13.886, 95% CI 1.014-190.243, P = 0.049; Cox proportional hazards model: HR = 13.909, 95% CI 1.086-178.150, P = 0.043), with more pronounced neutropenia and higher LDH, CRP and procalcitonin levels than other patients (P < 0.05). CONCLUSIONS In our breast cancer cohort, the severity of COVID-19 could be associated with baseline factors such as age over 75 and ECOG scores. Chemotherapy within 7 days before symptom onset could be a risk factor for severe COVID-19, reflected by neutropenia and elevated LDH, CRP and procalcitonin levels.
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Affiliation(s)
- Jielin Wei
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Mengjiao Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Jing Liu
- Department of Medical Oncology, Huanggang Central Hospital, Huanggang, Hubei, 438000, China
| | - Xu Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Hua Yang
- Department of Thyroid and Breast Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430014, China
| | - Pengfei Xia
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health and State Key Laboratory of Environmental Health (incubation), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Ling Peng
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yu Huang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Cuiwei Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zihan Xia
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Yanxia Zhao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
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Ibrahim N, Barruchet A, Moro MR, Blanchet C. Severe neutropenia in an anorexic adolescent girl: a stigma of underfeeding syndrome? Eat Weight Disord 2021; 26:1271-1275. [PMID: 32978756 DOI: 10.1007/s40519-020-01016-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We describe a case of severe, prolonged neutropenia in an adolescent girl hospitalized for anorexia nervosa (AN) which occurred during a refeeding procedure in the absence of refeeding syndrome. METHODS This case report includes retrospective anamnestic, clinical and biological data from the patient's medical record. A literature review was conducted on the haematological changes described in the undernutrition and refeeding periods, and also on recent data for underfeeding syndrome in patients with anorexia nervosa. CONCLUSION Leuconeutropenia is an adaptive condition observed in undernutrition in AN, usually rapidly and completely reversible in the course of refeeding and weight gain. We describe a rare case of severe, prolonged neutropenia despite appropriate care in the absence of refeeding syndrome and without gelatinous bone marrow transformation. We suggest that neutropenia in adolescent anorexia nervosa could be a stigma of underfeeding syndrome resulting from an overly cautious refeeding strategy. LEVEL OF EVIDENCE Level V, descriptive study.
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Affiliation(s)
- N Ibrahim
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
| | - A Barruchet
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
| | - M R Moro
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
- University of Paris, PCPP, 92100, Boulogne-Billancourt, France
- University of Paris-Saclay-UVSQ, INSERM, CESP, Team DevPsy, 94805, Villejuif, France
| | - C Blanchet
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France.
- University of Paris, PCPP, 92100, Boulogne-Billancourt, France.
- University of Paris-Saclay-UVSQ, INSERM, CESP, Team DevPsy, 94805, Villejuif, France.
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Abstract
BACKGROUND Monitoring of white cell counts during clozapine treatment leads to cessation of therapy if levels fall below predetermined values. Reductions in white cell counts, driven by lower levels of lymphocytes, have been observed with coronavirus disease 2019 (COVID-19). Neutropenia during COVID-19 has not been reported. We present data for 56 patients who were taking clozapine and had COVID-19. METHODS We included patients who were taking clozapine at the time they tested positive for COVID-19. We compared absolute neutrophil counts, lymphocyte counts and white cell counts between baseline and the first week of infection, and baseline and the second week of infection. RESULTS We observed reductions in absolute neutrophil counts (p = 0.005), lymphocyte counts (p = 0.003) and white cell counts (p < 0.001) between baseline and the first 7 days of COVID-19. All cell counts had returned to baseline levels by days 8 to 14. Six patients experienced neutropenia (absolute neutrophil counts < 2.0 × 109/L) and of those, 4 underwent mandatory cessation of clozapine. For 3 patients, clozapine treatment had been established for more than 6 months with no previous neutropenia, neutrophil levels returned to baseline within 2 weeks and no further neutropenia was observed on restarting treatment. LIMITATIONS This was a retrospective chart review; larger cohorts are required. Clozapine plasma levels were largely not measured by clinicians. CONCLUSION These data strongly suggest that mild neutropenia in the acute phase of COVID-19 in patients who are well established on clozapine is more likely to be a consequence of the virus than of clozapine treatment.
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Affiliation(s)
- Siobhan Gee
- From the Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom (Gee, Taylor); and the Institute of Pharmaceutical Sciences, King's College London, Franklin Wilkins Building, Stamford Street, London, United Kingdom (Gee, Taylor)
| | - David Taylor
- From the Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, United Kingdom (Gee, Taylor); and the Institute of Pharmaceutical Sciences, King's College London, Franklin Wilkins Building, Stamford Street, London, United Kingdom (Gee, Taylor)
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Uwagawa T, Sakamoto T, Yasuda J, Shiozaki H, Furukawa K, Onda S, Gocho T, Shiba H, Yanaga K. Phase II Study of Adjuvant Chemotherapy With Gemcitabine and Nafamostat Mesilate for Pancreatic Cancer. Pancreas 2021; 50:313-316. [PMID: 33835961 DOI: 10.1097/mpa.0000000000001767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to clarify the effectiveness of combination chemotherapy targeting gemcitabine (GEM)-induced nuclear factor kappa B as adjuvant therapy for pancreatic cancer. METHODS Patients who were planned after curative surgery (residual tumor classification R0 or R1) for pancreatic cancer to receive six cycles of adjuvant chemotherapy of regional arterial infusion of nafamostat mesilate with GEM between June 2011 and April 2017 were enrolled in this single-center, institutional review board-approved phase II trial (UMIN000006163). The Kaplan-Meier method was used to estimate disease-free survival and overall survival. RESULTS In 32 patients [male/female: 18/14; age: median, 65.5 years (range, 48-77 years); pathological stage (Union for International Cancer Control 8th): IA/IB/IIA/IIB/III, 2/2/9/18/1, respectively] who met the eligibility criteria, the median overall survival and disease-free survival were 36.4 months (95% confidence interval, 31.7-48.3) and 16.4 months (95% confidence interval, 14.3-22.0), respectively. Grade 4 treatment-related hematological toxicities were seen in 5 patients (15.6%) (all neutropenia). One patient developed grade 3 nonhematological toxicities (rash). CONCLUSIONS Adjuvant chemotherapy with regional arterial infusion of nafamostat mesilate and GEM is safe and has potential as an option in adjuvant setting after curative surgery for pancreatic cancer.
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Affiliation(s)
- Tadashi Uwagawa
- From the Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Ferreri AJM, Doorduijn JK, Re A, Cabras MG, Smith J, Ilariucci F, Luppi M, Calimeri T, Cattaneo C, Khwaja J, Botto B, Cellini C, Nassi L, Linton K, McKay P, Olivieri J, Patti C, Re F, Fanni A, Singh V, Bromberg JEC, Cozens K, Gastaldi E, Bernardi M, Cascavilla N, Davies A, Fox CP, Frezzato M, Osborne W, Liberati AM, Novak U, Zambello R, Zucca E, Cwynarski K. MATRix-RICE therapy and autologous haematopoietic stem-cell transplantation in diffuse large B-cell lymphoma with secondary CNS involvement (MARIETTA): an international, single-arm, phase 2 trial. Lancet Haematol 2021; 8:e110-e121. [PMID: 33513372 PMCID: PMC7844712 DOI: 10.1016/s2352-3026(20)30366-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Secondary CNS lymphoma is a rare but potentially lethal event in patients with diffuse large B-cell lymphoma. We aimed to assess the activity and safety of an intensive, CNS-directed chemoimmunotherapy consolidated by autologous haematopoietic stem-cell transplantation (HSCT) in patients with secondary CNS lymphoma. METHODS This international, single-arm, phase 2 trial was done in 24 hospitals in Italy, the UK, the Netherlands, and Switzerland. Adults (aged 18-70 years) with histologically diagnosed diffuse large B-cell lymphoma and CNS involvement at the time of primary diagnosis or at relapse and Eastern Cooperative Oncology Group Performance Status of 3 or less were enrolled and received three courses of MATRix (rituximab 375 mg/m2, intravenous infusion, day 0; methotrexate 3·5 g/m2, the first 0·5 g/m2 in 15 min followed by 3 g/m2 in a 3 h intravenous infusion, day 1; cytarabine 2 g/m2 every 12 h, in 1 h intravenous infusions, days 2 and 3; thiotepa 30 mg/m2, 30 min intravenous infusion, day 4) followed by three courses of RICE (rituximab 375 mg/m2, day 1; etoposide 100 mg/m2 per day in 500-1000 mL over a 60 min intravenous infusion, days 1, 2, and 3; ifosfamide 5 g/m2 in 1000 mL in a 24 h intravenous infusion with mesna support, day 2; carboplatin area under the curve of 5 in 500 mL in a 1 h intravenous infusion, day 2) and carmustine-thiotepa and autologous HSCT (carmustine 400 mg/m2 in 500 mL glucose 5% solution in a 1-2 h infusion, day -6; thiotepa 5 mg/kg in saline solution in a 2 h infusion every 12 h, days -5 and -4). The primary endpoint was progression-free survival at 1 year. Overall and complete response rates before autologous HSCT, duration of response, overall survival, and safety were the secondary endpoints. Analyses were in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT02329080. The trial ended after accrual completion; the database lock was Dec 31, 2019. FINDINGS Between March 30, 2015, and Aug 3, 2018, 79 patients were enrolled. 75 patients were assessable. 319 (71%) of the 450 planned courses were delivered. At 1 year from enrolment the primary endpoint was met, 42 patients were progression free (progression-free survival 58%; 95% CI 55-61). 49 patients (65%; 95% CI 54-76) had an objective response after MATRix-RICE, 29 (39%) of whom had a complete response. 37 patients who responded had autologous HSCT. At the end of the programme, 46 patients (61%; 95% CI 51-71) had an objective response, with a median duration of objective response of 26 months (IQR 16-37). At a median follow-up of 29 months (IQR 20-40), 35 patients were progression-free and 33 were alive, with a 2-year overall survival of 46% (95% CI 39-53). Grade 3-4 toxicity was most commonly haematological: neutropenia in 46 (61%) of 75 patients, thrombocytopenia in 45 (60%), and anaemia in 26 (35%). 79 serious adverse events were recorded in 42 (56%) patients; four (5%) of those 79 were lethal due to sepsis caused by Gram-negative bacteria (treatment-related mortality 5%; 95% CI 0·07-9·93). INTERPRETATION MATRix-RICE plus autologous HSCT was active in this population of patients with very poor prognosis, and had an acceptable toxicity profile. FUNDING Stand Up To Cancer Campaign for Cancer Research UK, the Swiss Cancer Research foundation, and the Swiss Cancer League.
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Affiliation(s)
- Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | | | | | | | - Jeffery Smith
- Department of Haematology, Aintree Hospital, Liverpool, UK
| | - Fiorella Ilariucci
- Division of Hematology, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Mario Luppi
- Azienda Ospedaliera Universitaria, UNIMORE, Modena, Italy
| | - Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Jahanzaib Khwaja
- Department of Haematology, University College Hospital, London, UK
| | - Barbara Botto
- AOU Città della salute e della Scienza, Turin, Italy
| | | | - Luca Nassi
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont and AOU Maggiore della Carità, Novara, Italy
| | - Kim Linton
- Department of Haemato-Oncology, The Christie Hospital, Manchester, UK
| | | | | | - Caterina Patti
- Division of Hematology, Azienda Villa Sofia-Cervello, Palermo, Italy
| | | | | | - Vikram Singh
- Department of Haematology, Aintree Hospital, Liverpool, UK
| | | | - Kelly Cozens
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elisabetta Gastaldi
- International Extranodal Lymphoma Study Group Coordinating Center, Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland
| | - Massimo Bernardi
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Cascavilla
- Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Andrew Davies
- Cancer Research UK Centre, University of Southampton, Southampton, UK
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Urban Novak
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Emanuele Zucca
- International Extranodal Lymphoma Study Group Coordinating Center, Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland; Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland; Medical Oncology Clinic, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
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Zinzani PL, Bregni M, Spione M, Mitterer M, Musuraca G, Bugli A, Piazza F, Pinto A. Effectiveness and Safety of Pixantrone for the Treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma in Every-Day Clinical Practice: The Italian Cohort of the PIXA Registry. Acta Haematol 2020; 144:259-263. [PMID: 33040061 DOI: 10.1159/000509923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Treatment of relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) represents a challenge for clinicians due to the lack of therapeutic options. DLBCL is not a rare disease in Italy. Pixantrone is an aza-anthracenedione, which, when compared to anthracyclines and anthracenediones, has a significantly reduced cardiotoxicity while maintaining good anti-tumor activity. However, the evidence on the use of pixantrone in the context of daily clinical practice is scarce. METHODS We focused on the Italian patient subset of a larger European retrospective study (the PIXA Registry) to assess the efficacy and safety of pixantrone in a real-life DLBCL population. The molecular profile of the disease and its impact on drug efficacy were also assessed. RESULTS Fifteen heavily pretreated DLBCL patients (13 males and 2 females) underwent treatment with pixantrone for a median of 2 cycles (range 1-6). Eight patients were bcl2 positive, 7 bcl6 positive, and 4 myc positive; 4 patients were diagnosed as double-hit, and 2 as triple-hit DLBCL. The overall response rate was 26.7% with a best response rate of 46.7%. Three patients had grade IV adverse events, which caused drug discontinuation. Four patients had 5 cases of grade III toxicities (1 thrombocytopenia, 1 stomatitis, and 3 neutropenia). One mild cardiac toxicity (sinus tachycardia for which no action was required) was possibly related to the study drug. CONCLUSION Our data documented drug efficacy that is satisfactory for this high-risk subset of patients with an acceptable toxicity profile. Results indicate that pixantrone could be a significant treatment option in patients with R/R aggressive DLBCL treated in everyday clinical practice.
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Affiliation(s)
- Pier Luigi Zinzani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Azienda Ospedaliero-Universitaria di Bologna, Università degli Studi di Bologna, Bologna, Italy,
| | | | | | | | - Gerardo Musuraca
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | | | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Antonello Pinto
- Istituto Nazionale Tumori Fondazione "G. Pascale", Naples, Italy
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Ngoi NYL, Heong V, Tang JI, Choo BA, Kumarakulasinghe NB, Lim D, Low M, Lim SE, Lim YW, Leong YH, Tseng M, Tong PSY, Ilancheran A, Low JJH, Ng J, Thian YL, Koh V, Tan DSP. Phase 1 Study of Low-Dose Fractionated Whole Abdominal Radiation Therapy in Combination With Weekly Paclitaxel for Platinum-Resistant Ovarian Cancer (GCGS-01). Int J Radiat Oncol Biol Phys 2020; 109:701-711. [PMID: 33045316 DOI: 10.1016/j.ijrobp.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Low-dose fractionated whole abdominal radiation therapy (LDFWART) has synergistic activity with paclitaxel in preclinical models. The aim of this phase 1 trial was to determine the recommended phase 2 dose and preliminary activity of weekly paclitaxel (wP) concurrent with LDFWART in patients with platinum-resistant ovarian cancer (PROC). METHODS AND MATERIALS Patients were enrolled at de-escalating dose levels of wP (part A), starting at 80 mg/m2, concurrent with fixed-dose LDFWART delivered in 60 cGy fractions twice-daily, 2 days per week, for 6 continuous weeks. After completing the 6-week course of wP + LDFWART, patients received wP until disease progression. Dose-limiting toxicity was evaluated during the first 3 weeks of wP + LDFWART. At wP (80 mg/m2) + LDFWART, no dose-limiting toxicities were observed; this was the established maximum tolerated dose. The trial was expanded (part B) with 7 additional patients with platinum-resistant, high-grade serous ovarian cancer to confirm toxicity and activity. RESULTS A total of 10 heavily pretreated patients were recruited (3 patients to part A, 7 patients to part B). They had received a median of 5 prior lines of therapy, and 70% of patients had received prior wP; 60% of patients completed 6 weeks of wP + LDFWART. Common related grade ≥3 adverse events were neutropenia (60%) and anemia (30%). Median progression-free survival was 3.2 months, and overall survival was 13.5 months. Of patients evaluable for response, 33% (3 of 9) achieved confirmed biochemical response (CA125 decrease >50% from baseline), 11% (1) achieved a partial response, and 5 patients had stable disease, giving a disease control rate of 66.7% (6 of 9). Four patients had durable disease control of ≥12 weeks, completing 12 to 21 weeks of wP. CONCLUSIONS The recommended phase 2 dose of wP + LDFWART for 6 weeks is 80 mg/m2. Encouraging efficacy in heavily pretreated PROC patients was observed, suggesting that further development of this therapeutic strategy in PROC should be considered.
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Affiliation(s)
- Natalie Y L Ngoi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Valerie Heong
- Department of Medical Oncology, Tan Tock Seng Hospital, Singapore
| | - Johann I Tang
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Bok Ai Choo
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | | | - Diana Lim
- Department of Pathology, National University Health System, Singapore
| | - Mellisa Low
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Siew Eng Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yi Wan Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Yiat Horng Leong
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Michelle Tseng
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Pearl S Y Tong
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Arunachalam Ilancheran
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Jeffrey J H Low
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Joseph Ng
- Division of Gynaecologic-Oncology, Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Yee Liang Thian
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Vicky Koh
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - David S P Tan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Cancer Science Institute, National University of Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Oh Y, Joung YS, Choi J. Incidence of Neutropenia with Valproate, Antipsychotics, and ADHD Medication Combination Treatment in Children and Adolescents. J Korean Med Sci 2020; 35:e226. [PMID: 32686368 PMCID: PMC7371460 DOI: 10.3346/jkms.2020.35.e226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022] Open
Abstract
This study's aim was to investigate whether the incidence of neutropenia was higher in subjects who received a combination pharmacotherapy with valproate (VPA), antipsychotics (APs), and attention deficit hyperactivity disorder (ADHD) medication than in those administered only VPA and APs combination pharmacotherapy. We conducted this study through retrospective review of medical records. We collected the records of 231 children admitted to the National Center for Mental Health. The incidence of neutropenia was significantly higher in the VPA-APs-ADHD combination group than in the other groups (55.2% vs. 25% vs. 12%, VPA + AP + ADHD vs. VPA + AP vs. AP). The presence of the combination of VPA, APs, and ADHD medication was a powerful predictor of neutropenia occurrence after adjusting for age, gender, and body mass index (odds ratio, 6.43; 95% confidence interval, 2.26-18.26; P < 0.001) The combination of VPA, APs, and ADHD medication in children with psychiatric disease appears to increase the incidence of drug-induced neutropenia.
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Affiliation(s)
- Yunhye Oh
- Department of Child and Adolescent Psychiatry, National Center for Mental Health, Seoul, Korea
- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo Sook Joung
- Department of Child and Adolescent Psychiatry, National Center for Mental Health, Seoul, Korea.
| | - Jungwon Choi
- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
BACKGROUND Glioblastoma is an uncommon but highly aggressive type of brain tumour. Significant gains have been achieved in the molecular understanding and the pathogenesis of glioblastomas, however clinical improvements are difficult to obtain for many reasons. The current standard of care involves maximal safe surgical resection followed by chemoradiation and then adjuvant chemotherapy European Organisation for Research and Treatment of Cancer and the NCIC Clinical Trials Group (EORTC-NCIC) protocol with a median survival of 14.6 months. Successive phase III international randomised controlled studies have failed to significantly demonstrate survival advantage with newer drugs. Epidermal growth factor receptor (EGFR) is observed to be aberrant in 30% to 60% of glioblastomas. The receptor aberrancy is driven by abnormal gene amplification, receptor mutation, or both, in particular the extracellular vIII domain. EGFR abnormalities are common in solid tumours, and the advent of anti-EGFR therapies in non-small cell lung cancer and colorectal adenocarcinomas have greatly improved clinical outcomes. Anti-EGFR therapies have been investigated amongst glioblastomas, however questions remain about its ongoing role in glioblastoma management. This review aimed to report on the available evidence to date and perform a systematic analysis on the risks and benefits of use of anti-EGFR therapies in glioblastomas. OBJECTIVES To evaluate the efficacy and harms of anti-EGFR therapies for glioblastoma in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, EBM Reviews databases, with supplementary handsearches to identify all available and relevant studies to 20 April 2020. SELECTION CRITERIA All randomised controlled trials (RCTs) using anti-EGFR therapies in adults with glioblastoma were eligible for inclusion. Anti-EGFR therapies included tyrosine kinase inhibitors, monoclonal antibodies, or vaccines. The comparison included investigational product added to standard of care versus standard of care or placebo, or investigational product against standard of care or placebo. DATA COLLECTION AND ANALYSIS The authorship team screened the search results and recorded the extracted data for analysis. We used standard Cochrane methodology to performed quantitative meta-analysis if two or more studies had appropriate and available data. Otherwise, we conducted a qualitative and descriptive analysis. We used the GRADE system to rate the certainty of the evidence. The analysis was performed along the two clinical settings: first-line (after surgery) and recurrent disease (after failure of first line treatment). Where information was available, we documented overall survival, progression-free survival, adverse events, and quality of life data from eligible studies. MAIN RESULTS The combined searches initially identified 912 records (after removal of duplicates), and further screening resulted in 19 records for full consideration. We identified nine eligible studies for inclusion in the review. There were three first-line studies and six recurrent studies. Five studies used tyrosine kinase inhibitors (TKIs); two studies used monoclonal antibodies; and two studies used targeted vaccines. More recent studies presented greater detail in the conduct of their studies and thus had a lower risk of bias. We observed no evidence benefit in overall survival with the use of anti-EGFR therapy in the first-line or recurrent setting (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76 to 1.04; 3 RCTs, 1000 participants, moderate-certainty evidence; and HR 0.79, 95% CI 0.51 to 1.21, 4 RCTs, 489 participants, low-certainty evidence, respectively). All the interventions were generally well tolerated with low-certainty evidence for lymphopenia (odds ratio (OR) 0.97, 95% CI 0.19 to 4.81; 4 RCTs, 1146 participants), neutropenia (OR 1.29, 95% CI 0.82 to 2.03; 4 RCTs, 1146 participants), and thrombocytopenia (OR 3.69, 95% CI 0.51 to 26.51; 4 RCTs, 1146 participants). A notable toxicity relates to ABT-414, where significant ocular issues were detected. The addition of anti-EGFR therapy showed no evidence of an increase in progression-free survival (PFS) in the first-line setting (HR 0.94, 95% CI 0.81 to 1.10; 2 RCTs, 894 participants, low-certainty evidence). In the recurrent setting, there was an increase in PFS with the use of anti-EGFR therapy (HR 0.75, 95% CI 0.58 to 0.96, 3 RCTs, 275 participants, low-certainty evidence). The available quality of life assessment data showed that anti-EGFR therapies were neither detrimental or beneficial when compared to standard care (not estimable). AUTHORS' CONCLUSIONS In summary, there is no evidence of a demonstrable overall survival benefit with the addition of anti-EGFR therapy in first-line and recurrent glioblastomas. Newer drugs that are specially designed for glioblastoma targets may raise the possibility of success in this population, but data are lacking at present. Future studies should be more selective in pursuing people displaying specific EGFR targets.
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Affiliation(s)
- Adrian Lee
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | | | - David Lok Hang Chan
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Mustafa Khasraw
- NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, Australia
| | - Viive M Howell
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Helen Wheeler
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
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Abstract
This review focuses on recent advances in the field of cytomegalovirus (CMV). The 2 main strategies for CMV prevention are prophylaxis and preemptive therapy. Prophylaxis effectively prevents CMV infection after solid organ transplantation (SOT) but is associated with high rates of neutropenia and delayed-onset postprophylaxis disease. In contrast, preemptive therapy has the advantage of leading to lower rates of CMV disease and robust humoral and T-cell responses. It is widely used in hematopoietic cell transplant recipients but is infrequently utilized after SOT due to logistical considerations, though these may be overcome by novel methods to monitor CMV viremia using self-testing platforms. We review recent developments in CMV immune monitoring, vaccination, and monoclonal antibodies, all of which have the potential to become part of integrated strategies that rely on viral load monitoring and immune responses. We discuss novel therapeutic options for drug-resistant or refractory CMV infection, including maribavir, letermovir, and adoptive T-cell transfer. We also explore the role of donor factors in transmitting CMV after SOT. Finally, we propose a framework with which to approach CMV prevention in the foreseeable future.
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Affiliation(s)
- Ghady Haidar
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Boeckh
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Nina Singh
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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